Medical Specialty: Gastroenterology
Sample Name: Deglutition Study - Modified Barium swallow

EXAM: , Modified barium swallow.,SYMPTOM:,  Dysphagia with possible aspiration.,FINDINGS:,  A cookie deglutition study was performed.  The patient was examined in the direct lateral position.,Patient was challenged with thin liquids, thick liquid, semisolids and solids.,Persistently demonstrable is the presence of penetration with thin liquids.  This is not evident with thick liquids, semisolids or solids.,There is weakness in the oral phase of deglutition.  Subglottic region appears normal.  There is no evidence of aspiration demonstrated.,IMPRESSION: , Penetration demonstrated with thin liquids with weakness of the oral phase of deglutition.
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DESCRIPTION: Modified Barium swallow (Deglutition Study) for Dysphagia with possible aspiration.

gastroenterology, aspiration, deglutition study, thin liquids, thick liquid, semisolids, solids, modified barium swallow, barium swallow, dysphagia, deglutition,

The situation involves a medical test result for a patient experiencing dysphagia with potential aspiration issues, both of which can pose significant health risks. While the test shows penetration with thin liquids, there's no evidence of aspiration, which reduces immediate severity. This is an important finding that guides further treatment decisions to prevent possible complications like aspiration pneumonia. Thus, the stakes are moderate to high given the potential implications for patient care.


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

Medical Specialty: Surgery
Sample Name: YAG Laser Capsulotomy - 1

PREOPERATIVE DIAGNOSIS: , Secondary capsular membrane, right eye.,POSTOPERATIVE DIAGNOSIS: , Secondary capsular membrane, right eye.,PROCEDURE PERFORMED: , YAG laser capsulotomy, right eye.,INDICATIONS: , This patient has undergone cataract surgery, and vision is reduced in the operated eye due to presence of a secondary capsular membrane.  The patient is being brought in for YAG capsular discission.,PROCEDURE: , The patient was seated at the YAG laser, the pupil having been dilated with 1%  Mydriacyl, and Iopidine was instilled.  The Abraham capsulotomy lens was then positioned and applications of laser energy in the pattern indicated on the outpatient note were applied.  A total of
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DESCRIPTION: This patient has undergone cataract surgery, and vision is reduced in the operated eye due to presence of a secondary capsular membrane.  The patient is being brought in for YAG capsular discission.

surgery, abraham capsulotomy, yag, yag laser capsulotomy, capsulotomy, laser, membrane, eye, capsular,

YAG laser capsulotomy is a common, routine outpatient procedure following cataract surgery to clear a secondary capsular membrane, which can obscure vision. While ensuring proper technique and care is important, the procedure itself is low-risk and typical in ophthalmic practice. Complications are rare and the stakes, in terms of potential harm, are not high compared to other surgical procedures.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Mediastinal Exploration

TITLE OF OPERATION:,  Mediastinal exploration and delayed primary chest closure.,INDICATION FOR SURGERY:,  The patient is a 12-day-old infant who has undergone a modified stage I Norwood procedure with a Sano modification.  The patient experienced an unexplained cardiac arrest at the completion of the procedure, which required institution of extracorporeal membrane oxygenation for more than two hours following discontinuation of cardiopulmonary bypass.  The patient has been successfully resuscitated with extracorporeal membrane oxygenation and was decannulated 48 hours ago.  She did not meet the criteria for delayed primary chest closure.,PREOP DIAGNOSIS: , Open chest status post modified stage I Norwood procedure.,POSTOP DIAGNOSIS: , Open chest status post modified stage I Norwood procedure.,ANESTHESIA:,  General endotracheal.,COMPLICATIONS:,  None.,FINDINGS: , No evidence of intramediastinal purulence or hematoma.  At completion of the procedure no major changes in hemodynamic performance.,DETAILS OF THE PROCEDURE: , After obtaining informed consent, the patient was brought to the room, placed on the operating room table in supine position.  Following the administration of general endotracheal anesthesia, the chest was prepped and draped in the usual sterile fashion and all the chest drains were removed.  The chest was then prepped and draped in the usual sterile fashion and previously placed segmental AlloDerm was removed.  The mediastinum was then thoroughly irrigated with diluted antibiotic irrigation and both pleural cavities suctioned.  Through a separate incision and another 15-French Blake drain was inserted and small titanium clips were utilized to mark the rightward aspect of the RV-PA connection as well as inferior most aspect of the ventriculotomy.  The pleural spaces were opened widely and the sternum was then spilled with vancomycin paste and closed the sternum with steel wires.  The subcutaneous tissue and skin were closed in layers.  There was no evidence of significant increase in central venous pressure or desaturation.  The patient tolerated the procedure well.  Sponge and needle counts were correct times 2 at the end of the procedure.  The patient was transferred to the Pediatric Intensive Care Unit shortly thereafter in critical but stable condition.,I was the surgical attending present in the operating room in charge of the surgical  procedure throughout the entire length of the case.
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DESCRIPTION: Mediastinal exploration and delayed primary chest closure.  The patient is a 12-day-old infant who has undergone a modified stage I Norwood procedure with a Sano modification.

cardiovascular / pulmonary, mediastinal exploration, delayed primary chest closure, extracorporeal membrane oxygenation, stage i norwood procedure, sano modification, chest closure, infant, mediastinal, exploration, closure, endotracheal, chest

The situation involves a high-stakes surgical procedure on a very young infant with a complex heart condition. The infant underwent a modified stage I Norwood procedure, which is a critical heart surgery, and experienced cardiac arrest requiring extracorporeal membrane oxygenation (ECMO). The fact that the patient is in critical but stable condition and needed another surgical procedure (mediastinal exploration and delayed primary chest closure) indicates the seriousness of the situation. The stakes are high due to the patient's age, the complexity of the condition and procedure, and the critical post-operative management requirements.


Medical Specialty: General Medicine
Sample Name: Gen Med Consult - 38

Chief Complaint:, Abdominal pain, nausea and vomiting.,History of Present Illness:, A 50-year-old Asian female comes to The Methodist Hospital on January 2, 2001, complaining of a 3-day history of abdominal pain. The pain is described as crampy in the central part of her abdomen, and is associated with nausea and vomiting during the previous 24 hours. The patient denied passing any stool or gas per rectum for the previous 24 hours. She had been admitted recently to the hospital from December 19 to December 23, 2000, with a three-week history of fevers to 101.8, diaphoresis, anorexia, malaise and skin "lumps". She described a total of three "lumps". The first one started as a pin-sized lesion that grew up and then disappeared, the other two didn't resolve. They were described as "erythematous nodular lesions on the extensor surface of the left arm." A punch biopsy was obtained from these skin lesions, showing deep dermis and subcutaneous adipose tissue that contained "multiple granulomas composed of histiocytes and multinucleated giant cells without caseating necrosis". However, one granuloma in the deep dermis, showed a hint of central necrosis. Special stains for acid - fast bacilli and fungi were reported as negative. No atypia or malignancy was noted. A CT scan of the chest was obtained on December 19, 2000 and showed numerous masses with spiculated borders bilaterally, predominately in the upper lobes and superior segments of the lower lobes. No cavitary lesions, mediastinal masses or definite hilar adenopathy were reported. The patient underwent bronchoscopy and transbronchial biopsy which showed fragments of bronchial mucosa and wall with underlying lung parenchyma. Minimal to mild interstitial lymphocytes with a few microfoci of neutrophils were seen. They were also able to appreciate intra-alveolar fibrinous exudates. One of the blood cultures drawn on December 19, 2000 grew Streptococcus mitis.,The patient was discharged on ethambutol 1200 mg po qd, clarithromycin 500 mg po bid, ampicillin 500 mg po q 6h and fluconazole 200 mg po qd.,Past Medical History:,1. Post-streptococcal glomerulonephritis at age 10.,2. End stage renal disease diagnosed in 1994, on peritoneal dialysis until 1996.,3. Cadaveric transplant in October 1996,4. Steroid induced diabetes mellitus,5. Hypertension,Past Surgical History:,1. Total abdominal hysterectomy in January 1996,2. Cesarean section X2 in 1996 and 1997,3. Appendectomy in 1971,4. Insertion of peritoneal dialysis catheter in 1994,5. Cadaveric transplant in October 1996,Social History:,The patient denies a history of smoking, drinking or intravenous drug use. She came to the United States in 1973. She works as a nurse in a newborn nursery. Her hobby is gardening. She traveled to Las Vegas on May 2000 and stayed for 6 months. She denied ill contacts or pets.,Allergies:, Ciprofloxacin and Enteric coated aspirin,Medications:, prednisone 20 mg po qd, enalapril 2.5 mg po qd, clonidine patch TTS 3 1/week, Prograf 5 mg po bid, ranitidine 150 mg po bid, furosemide 40 mg po bid, atorvastatin 10 mg po qd, multivitamins 1 tab po qd, estrogen patch, fluconazole 200 mg po qd, metformin 500 mg po bid, glyburide 10 mg po qd, clarithromycin 500 mg po bid, ethambutol 1200 mg po qd, ampicillin 500 mg po q 6h.,Family History:, She described a family history of hypertension. Her mother died after a myocardial infarction at age 59. Her father was diagnosed with congestive heart failure and had a pacemaker placed.,Review of systems:, Non-contributory. The patient denied fever, chills, ulcers, liver disease or history of gallstones.,Vaccines: The patient was vaccinated with BCG before starting elementary school in the Philippines.,Physical Examination:, At the time of the examination the patient was alert and oriented times three and in no acute distress. She was well nourished.,BP 106/60 lying down; HR 86; RR 12; T 96.1° F; Hgt. =5' 2"; Wgt. =121 lbs.,SKIN: There was no rash or skin lesions.,HEENT: She had no oral lesions and moist mucous membranes. No icterus was noted.,NECK: Her neck was supple without lymphadenopathy or thyromegaly.,LUNGS: Crackles at the right lower base with normal respiratory excursion and no dullness to percussion.,HEART: IV/VI crescendo - decrescendo systolic murmur was heard at the second intercostal space with radiation to the neck.,ABDOMEN: The abdomen was distended. Bowel sounds were normal. No hepatosplenomegaly, tenderness or rebound tenderness could be detected during the examination.,EXTREMITIES: No cyanosis, clubbing or edema was noted.,RECTAL: Normal rectal exam. Guaiac negative.,NEUROLOGIC: Normal and non-focal.,Hospital Course:,  The patient was admitted and a nasogastric tube was placed. IV fluids were started. A KUB was obtained showing an abnormal bowel gas pattern. Multiple loops of distended bowel were noted in the mid abdomen. Air and feces were noted within the colon in the right side. An Abdominal CT scan was obtained. There was a small amount of perihepatic fluid noted. The liver and spleen were normal. The kidneys were atrophic. The gallbladder was moderately distended. There was marked dilatation of the small bowel proximally and distally. There was gas and contrast material in the colon. A diagnostic procedure was performed.
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DESCRIPTION: Patient admitted with abdominal pain, nausea and vomiting.

The situation involves a middle-aged female patient with a complex medical history, including a recent hospital admission with multiple symptoms and diagnostic procedures. Her current issues with abdominal pain, nausea, vomiting, and a lack of bowel movements raise significant concerns, indicating a possible serious gastrointestinal condition, such as an obstruction or other acute abdominal issue, which requires immediate medical attention. The presence of a systemic infection or an unresolved condition from prior health issues, as suggested by her complicated medical history and recent antibiotics use, adds to the urgency and complexity of her care. Given her history of end-stage renal disease and other chronic health conditions, any acute medical issue can significantly impact her overall health. This scenario is high-stakes due to the potential for a life-threatening condition requiring urgent intervention.


Medical Specialty: Hematology - Oncology
Sample Name: Parathyroid Adenoma Excision

PREOPERATIVE DIAGNOSIS:,  Right superior parathyroid adenoma.,POSTOPERATIVE DIAGNOSIS:,  Right superior parathyroid adenoma.,PROCEDURE: , Excision of right superior parathyroid adenoma.,ANESTHESIA:,  Local with 1% Xylocaine and anesthesia standby with sedation.,CLINICAL HISTORY:,  This 80-year-old woman has had some mild dementia.  She was begun on Aricept but could not tolerate that because of strange thoughts and hallucinations.  She was found to be hypercalcemic.  Intact PTH was mildly elevated.  A sestamibi parathyroid scan and an ultrasound showed evidence of a right superior parathyroid adenoma.,FINDINGS AND PROCEDURE:,  The patient was placed on the operating table in the supine position.  A time out was taken so that the anesthesia personnel, nursing personnel, surgical team, and patient could confirm the patient's identity, operative site and operative plan.  The electronic medical record was reviewed as was the ultrasound.  The patient was sedated.  A small roll was placed behind the shoulders to moderately hyperextend the neck.  The head was supported in a foam head cradle.  The neck and chest were prepped with chlorhexidine and isolated with sterile drapes.  After infiltration with 1% Xylocaine with epinephrine along the planned incision, a transverse incision was made in the skin crease a couple of centimeters above the clavicular heads and carried down through the skin, subcutaneous tissue, and platysma.  The larger anterior neck veins were divided between 4-0 silk ligatures.  Superior and inferior flaps were developed in the subplatysmal plane using electrocautery and blunt dissection.  The sternohyoid muscles were separated in the midline, and the right sternohyoid muscle was retracted laterally.  The right sternothyroid muscle was divided transversely with the cautery.  The right middle thyroid vein was divided between 4-0 silk ligatures.  The right thyroid lobe was rotated leftward.  Posterior to the mid portion of the left thyroid lobe, a right superior parathyroid adenoma of moderate size was identified.  This was freed up and its pedicle was ligated with small Hemoclips and divided and the gland was removed.  It was sent for weight and frozen section.  It weighed 960 mg and on frozen section was consistent with a parathyroid adenoma.,Prior to the procedure, a peripheral blood sample had been obtained and placed in a purple top tube labeled "pre-excision."  It was our intention to monitor intraoperative intact parathyroid hormone 10 minutes after removal of this parathyroid adenoma.  However, we could not obtain 3 cc of blood from either the left foot or the left arm after multiple attempts, and therefore, we decided that the chance of cure of hyperparathyroidism by removal of this parathyroid adenoma was high enough and the improvement in that chance of cure marginal enough that we would terminate the procedure without monitoring PTH.  The neck was irrigated with saline and hemostasis found to be satisfactory.  The sternohyoid muscles were reapproximated with interrupted 4-0 Vicryl.  The platysma was closed with interrupted 4-0 Vicryl, and the skin was closed with subcuticular 5-0 Monocryl and Dermabond.  The patient was awakened and taken to the recovery area in satisfactory condition having tolerated the procedure well.
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DESCRIPTION: Excision of right superior parathyroid adenoma, seen on sestamibi parathyroid scan and an ultrasound.

hematology - oncology, parathyroid adenoma, superior parathyroid adenoma, excision, sestamibi parathyroid scan, sestamibi parathyroid, parathyroid scan, sternohyoid muscles, superior parathyroid, parathyroid, sestamibi, platysma, adenoma, ultrasound, sternohyoid, thyroid, muscles

The situation involves a surgical procedure for the excision of a parathyroid adenoma in an elderly patient with mild dementia and hypercalcemia. While the surgery is significant, it appears to have been routine and completed without complications. The surgeon made a decision not to monitor intraoperative PTH due to difficulties in obtaining blood samples, judging that the procedure addressed the primary issue. Given the patient's age and preexisting conditions, there is some risk involved, but the stakes seem moderate based on the information provided and typical outcomes of such surgeries.


Medical Specialty: Surgery
Sample Name: Circumcision - 2

CIRCUMCISION - NEONATAL,PROCEDURE:,:  The procedure, risks and benefits were explained to the patient's mom, and a consent form was signed.  She is aware of the risk of bleeding, infection, meatal stenosis, excess or too little foreskin removed and the possible need for revision in the future.  The infant was placed on the papoose board.  The external genitalia were prepped with Betadine.  A penile block was performed with a 30-gauge needle and 1.5 mL of Nesacaine without epinephrine.,Next, the foreskin was clamped at the 12 o'clock position back to the appropriate proximal extent of the circumcision on the dorsum of the penis.  The incision was made.  Next, all the adhesions of the inner preputial skin were broken down.  The appropriate size bell was obtained and placed over the glans penis.  The Gomco clamp was then configured, and the foreskin was pulled through the opening of the Gomco.  The bell was then placed and tightened down.  Prior to do this, the penis was viewed circumferentially, and there was no excess of skin gathered, particularly in the area of the ventrum.  A blade was used to incise circumferentially around the bell.  The bell was removed.  There was no significant bleeding, and a good cosmetic result was evident with the appropriate amount of skin removed.,Vaseline gauze was then placed.  The little boy was given back to his mom.,PLAN:,  They have a new baby checkup in the near future with their primary care physician.  I will see them back on a p.r.n. basis if there are any problems with the circumcision.
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DESCRIPTION: Circumcision procedure (neotal)

Circumcision procedure (neotal)

surgery, neonatal, circumcision, gomco, gomco clamp, external genitalia, foreskin, glans, glans penis, infant, meatal stenosis, penile block, penis, preputial skin, circumferentially, infection, bell,

The situation involves a neonatal circumcision, a common surgical procedure. While circumcision is generally considered a routine and low-risk procedure, it involves surgical techniques and potential risks such as bleeding, infection, or complications that might necessitate future correction. The written consent from the mother indicates awareness of these risks. Although not critically high-stakes compared to more invasive surgeries, it requires precision and care due to the young age and vulnerability of the patient.


Medical Specialty: Pediatrics - Neonatal
Sample Name: Atopic Eczema

SUBJECTIVE:,  This 1+ year, black female, new patient in dermatology, sent in for consult from ABC Practice for initial evaluation of a lifelong history of atopic eczema.  The patient’s mom is from Tanzania.  The patient has been treated with Elidel cream b.i.d. for six months but apparently this has stopped working now and it seems to make her more dry and plus she has been using some Johnson's Baby Oil on her.  The patient is a well-developed baby.  Appears stated age.  Overall health is good.,FAMILY, SOCIAL, AND ALLERGY HISTORY: , The patient has eczema and a positive atopic family history.  No psoriasis.  No known drug allergies.,CURRENT MEDICATIONS:,  None.,PHYSICAL EXAMINATION:, The patient has eczematous changes today on her face, trunk, and extremities.,IMPRESSION:,  Atopic eczema.,TREATMENT:,1.  Discussed condition and treatment with Mom.,2.  Continue bathing twice a week.,3.  Discontinue hot soapy water.,4.  Discontinue Elidel for now.,5.  Add Aristocort cream 0.25%, Polysporin ointment, Aquaphor b.i.d. and p.r.n. itch.  We will see her in one month if not better otherwise on a p.r.n. basis.  Send a letter to ABC Practice program.
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DESCRIPTION: 1+ year, black female for initial evaluation of a lifelong history of atopic eczema.

pediatrics - neonatal, dermatology, elidel cream, johnson's baby oil, polysporin ointment, atopic eczema, eczema, eczematous, hot soapy water, atopic, elidel,

The situation involves the medical evaluation and management of a 1-year-old child with atopic eczema. While managing eczema is important for the patient's quality of life, it is not typically life-threatening or an acute medical emergency. The situation requires careful assessment and treatment adjustments but does not carry immediate high-stakes consequences like life-saving interventions. Ensuring effective management is crucial, but the stakes are not extremely high as it concerns long-term care more than acute life-threatening issues.


Medical Specialty: Pain Management
Sample Name: Coccygeal injection

COCCYGEAL INJECTION,PROCEDURE:,:  Informed consent was obtained from the patient.  A gloved little finger was inserted into the anal region and the sacral/coccygeal joint was palpated and the coccyx was moved and it was confirmed that this reproduced pain.  After aseptic cleaning, a 25-gauge needle was inserted through the skin into the sacral/coccygeal joint.  It was confirmed that the needle was not entering the rectal cavity by finger placed in the rectum.  After aspiration, 1 mL of cortisone and 2 mL of 0.25% Marcaine were injected at the site.  Postprocedure, the needle was withdrawn.  A small pressure dressing was placed and no hematoma was observed to form.,POST PROCEDURE INSTRUCTIONS:, The patient has been asked to report to us any redness, swelling, inflammation, or fevers.  The patient has been asked to restrict the use of the * extremity for the next 24 hours.
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DESCRIPTION: Coccygeal injection

Coccygeal injection

pain management, coccygeal injection, 0.25% marcaine, 1 ml of cortisone, coccygeal joint, coccyx, fevers, inflammation, redness, sacral, swelling, coccygeal, injectionNOTE,: 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.

While the procedure involves injecting medication into the sacral/coccygeal joint to manage pain, it is a routine medical procedure in the field of pain management. The potential risks, such as infection, hematoma, or adverse reaction to the injection, are typically minimal when proper technique and precautions are followed. However, the procedure does involve direct interaction with sensitive regions and the spine, therefore requiring careful handling and monitoring for complications. Thus, the situation can be considered moderate-stakes due to the potential for complications if not performed correctly or if post-procedure instructions are not followed.


Medical Specialty: Consult - History and Phy.
Sample Name: Orthopedic Consult - 4

CHIEF COMPLAINT: , Chronic low back, left buttock and leg pain.,HISTORY OF PRESENT ILLNESS: , This is a pleasant 49-year-old gentleman post lumbar disc replacement from January 2005.  Unfortunately, the surgery and interventional procedures have not been helpful in alleviating his pain.  He has also tried acupuncture, TENS unit, physical therapy, chiropractic treatment and multiple neuropathic medications including Elavil, Topamax, Cymbalta, Neurontin, and Lexapro, which he discontinued either due to side effects or lack of effectiveness in decreasing his pain.  Most recently, he has had piriformis injections, which did give him a brief period of relief; however, he reports that the Botox procedure that was done on March 8, 2006 has not given him any relief from his buttock pain.  He states that approximately 75% of his pain is in his buttock and leg and 25% in his back.  He has tried to increase in his activity with walking and does note increased spasm with greater activity in the low back.  He rated his pain today as 6/10, describing it is shooting, sharp and aching.  It is increased with lifting, prolonged standing or walking and squatting, decreased with ice, reclining and pain medication.  It is constant but variable in degree.  It continues to affect activities and sleep at night as well as mood at times.  He is currently not satisfied completely with his level of pain relief.,MEDICATIONS: , Kadian 30 mg b.i.d., Zanaflex one-half to one tablet p.r.n. spasm, and Advil p.r.n.,ALLERGIES:,  No known drug allergies.,REVIEW OF SYSTEMS:,  Complete multisystem review was noted and signed in the chart.,SOCIAL HISTORY:,  Unchanged from prior visit.,PHYSICAL EXAMINATION: , Blood pressure 123/87, pulse 89, respirations 18, and weight 220 lbs.  He is a well-developed obese male in no acute distress.  He is alert and oriented x3, and displays normal mood and affect with no evidence of acute anxiety or depression.  He ambulates with normal gait and has normal station.  He is able to heel and toe walk.  He denies any sensory changes.,ASSESSMENT & PLAN: , This is a pleasant 49-year-old with chronic pain plus lumbar disk replacement with radiculitis and myofascial complaints.  We discussed treatment options at length and he is willing to undergo a trial of Lyrica.,He is sensitive to medications based on his past efforts and is given a prescription for 150 mg that he will start at bedtime.  We discussed the up taper schedule and he understands that he will have to be on this for some time before we can decide whether or not it is helpful to him.  We also briefly touched on the possibility of a spinal cord stimulator trial if this medication is not helpful to him.  He will call me if there are any issues with the new prescription and follow in four weeks for reevaluation.
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DESCRIPTION: Patient with chronic pain plus lumbar disk replacement with radiculitis and myofascial complaints.

consult - history and phy., radiculitis, myofascial, acupuncture, tens unit, physical therapy, chiropractic treatment, lumbar disk replacement, lumbar disk, disk replacement, orthopedic

The situation involves a 49-year-old patient suffering from chronic pain following a lumbar disc replacement. Despite undergoing various treatments and interventions, the pain persists and affects his daily activities and sleep. This suggests a significant impact on the patient's quality of life. While chronic pain management is important, it does not typically constitute an immediate, life-threatening situation. However, finding effective pain management solutions is critical for improving his quality of life and mental well-being, as chronic pain can also lead to psychological issues. Given the complexity of his condition and the current exploration of new medication, there's a moderate level of stakes involved.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Low-Transverse C-Section - 8

PREOPERATIVE DIAGNOSES,1.  Intrauterine pregnancy at 35-1/7.,2.  Rh isoimmunization.,3.  Suspected fetal anemia.,4.  Desires permanent sterilization.,POSTOPERATIVE DIAGNOSES,1.  Intrauterine pregnancy at 35-1/7.,2.  Rh isoimmunization.,3.  Suspected fetal anemia.,4.  Desires permanent sterilization.,OPERATION PERFORMED: , Primary low transverse cesarean section by Pfannenstiel skin incision with bilateral tubal sterilization.,ANESTHESIA:,  Spinal anesthesia.,COMPLICATIONS:  ,None.,ESTIMATED BLOOD LOSS:  ,500 mL.,INTRAOPERATIVE FLUIDS: , 1000 mL crystalloids.,URINE OUTPUT: , 300 mL clear urine at the end of procedure.,SPECIMENS:,  Cord gases, hematocrit on cord blood, placenta, and bilateral tubal segments.,INTRAOPERATIVE FINDINGS: , Male infant, vertex position, very bright yellow amniotic fluid.  Apgars 7 and 8 at 1 and 5 minutes respectively.  Weight pending at this time.  His name is Kasson as well as umbilical cord and placenta stained yellow.  Otherwise normal appearing uterus and bilateral tubes and ovaries.,DESCRIPTION OF OPERATION:,  After informed consent was obtained, the patient was taken to the operating room where spinal anesthesia was obtained by Dr. X without difficulties.  The patient was placed in supine position with leftward tilt.  Fetal heart tones were checked and were 140s, and she was prepped and draped in a normal sterile fashion.  At this time, a Pfannenstiel skin incision made with a scalpel and carried down to the underlying fascia with electrocautery.  The fascia was nicked sharply in the midline.  The fascial incision was extended laterally with Mayo scissors.  The inferior aspect of the fascial incision was grasped with Kocher x2, elevated, and rectus muscles dissected sharply with the use of Mayo scissors.  Attention was then turned to the superior aspect of the fascial incision.  Fascia was grasped, elevated, and rectus muscles dissected off sharply.  The rectus muscles were separated in the midline bluntly.  The peritoneum was identified, grasped, and entered sharply and the peritoneal incision extended inferiorly and superiorly with good visualization of bladder.  Bladder blade was inserted.  Vesicouterine peritoneum was tented up and a bladder flap was created using Metzenbaum scissors.  Bladder blade was reinserted to effectively protect the bladder from the operative field and the lower uterine segment incised in a transverse U-shaped fashion with the scalpel.  Uterine incision was extended laterally and manually.  Membranes were ruptured and bright yellow clear amniotic fluid was noted.  Infant's head was in a floating position, able to flex the head, push against the incision, and then easily brought it to the field vertex.  Nares and mouth were suctioned with bulb suction.  Remainder of the infant was delivered atraumatically.  The infant was very pale upon delivery.  Cord was doubly clamped and cut and immediately handed to the awaiting intensive care nursery team.  An 8 cm segment of the tube was doubly clamped and transected.  Cord gases were obtained.  Cord was then cleansed, laid on a clean laparotomy sponge, and cord blood was drawn for hematocrit measurements.  At this time, it was noted that the cord was significantly yellow stained as well as the placenta.  At this time, the placenta was delivered via gentle traction on the cord and exterior uterine massage.  Uterus was exteriorized and cleared off all clots and debris with dry laparotomy sponge and the lower uterine segment was closed with 1-0 chromic in a running locked fashion.  Two areas of oozing were noted and separate figure-of-eight sutures were placed to obtain hemostasis.  At this time, the uterine incision was hemostatic.  The bladder was examined and found to be well below the level of the incision repair.  Tubes and ovaries were examined and found to be normal.  The patient was again asked if she desires permanent sterilization of which she agrees and therefore the right fallopian tube was identified and followed out to the fimbriated end and grasped at the mid portion with a Babcock clamp.  Mesosalpinx was divided with electrocautery and a 4-cm segment of tube was doubly tied and transected with a 3-cm segment of tube removed.  Hemostasis was noted.  Then, attention was turned to the left fallopian tube which in similar fashion was grasped and brought out through the fimbriated end and grasped the midline portion with Babcock clamp.  Mesosalpinx was incised and 3-4 cm tube doubly tied, transected, and excised and excellent hemostasis was noted.  Attention was returned to the uterine incision which is seemed to be hemostatic and uterus was returned to the abdomen.  Gutters were cleared off all clots and debris.  Lower uterine segments were again re-inspected and found to be hemostatic.  Sites of tubal sterilization were also visualized and were hemostatic.  At this time, the peritoneum was grasped with Kelly clamps x3 and closed with running 3-0 Vicryl suture.  Copious irrigation was used.  Rectus muscle belly was examined and found to be hemostatic and tacked and well approximated in the midline.  At this time, the fascia was closed using 0 Vicryl in a running fashion.  Manual palpation confirms thorough and adequate closure of the fascial layer.  Copious irrigation was again used.  Hemostasis noted, and skin was closed with staples.  The patient tolerated the procedure well.  Sponge, lap, needle, and instrument counts were correct x3 and the patient was sent to the recovery room awake and stable condition.  Infant assumed the care of the intensive care nursery team and being followed and workup up for isoimmunization and fetal anemia.  The patient will be followed for her severe right upper quadrant pain post delivery.  If she continues to have pain, may need a surgical consult for gallbladder and/or angiogram for evaluation of right kidney and questionable venous plexus.  This all will be relayed to Dr. Y, her primary obstetrician who was on call starting this morning at 7 a.m. through the weekend.
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DESCRIPTION: Primary low transverse cesarean section by Pfannenstiel skin incision with bilateral tubal sterilization.   Intrauterine pregnancy at 35-1/7.  Rh isoimmunization.  Suspected fetal anemia.  Desires permanent sterilization.

obstetrics / gynecology, intrauterine pregnancy, rh isoimmunization, primary low transverse cesarean section, bilateral tubal sterilization, pfannenstiel skin incision, fascial incision, uterine incision, fetal anemia, permanent sterilization, rectus muscles, incision, tubes, cord,

The situation described involves a cesarean section at 35 weeks of pregnancy, a significant medical procedure with serious implications for both mother and child. The conditions described, including Rh isoimmunization and suspected fetal anemia, add complexity and urgency to this scenario. The outcome of this procedure directly impacts the health and well-being of the mother and the newborn, both of whom may face potential complications due to these conditions. Additionally, the mother's desire for permanent sterilization adds another layer of complexity to the surgery. While the procedure was reported to have no immediate complications, the stakes remain high due to the nature of the medical conditions involved and the significant life events occurring (i.e., delivery and sterilization).


Medical Specialty: General Medicine
Sample Name: Possible Spider Bite

SUBJECTIVE:,  This 47-year-old white female presents with concern about possible spider bite to the left side of her neck.  She is not aware of any specific injury.  She noticed a little tenderness and redness on her left posterior shoulder about two days ago.  It seems to be getting a little bit larger in size, and she saw some red streaks extending up her neck.  She has had no fever.  The area is very minimally tender, but not particularly so.,CURRENT MEDICATIONS:,  Generic Maxzide, Climara patch, multivitamin, Tums, Claritin, and vitamin C.,ALLERGIES:,  No known medicine allergies.,OBJECTIVE:,Vital Signs:  Weight is 150 pounds.  Blood pressure 122/82.,Extremities:  Examination of the left posterior shoulder near the neckline is an area of faint erythema which is 6 cm in diameter.  In the center is a tiny mark which could certainly be an insect or spider bite.  There is no eschar there, but just a tiny marking.  There are a couple of erythematous streaks extending towards the neck.,ASSESSMENT:,  Possible insect bite with lymphangitis.,PLAN:,1.  Duricef 1 g daily for seven days.,2.  Cold packs to the area.,3.  Discussed symptoms that were suggestive of the worsening, in which case she would need to call me.,4.  Incidentally, she has noticed a little bit of dryness and redness on her eyelids, particularly the upper ones’ and the lower lateral areas.  I suspect she has a mild contact dermatitis and suggested hydrocortisone 1% cream to be applied sparingly at bedtime only.
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DESCRIPTION: A 47-year-old white female presents with concern about possible spider bite to the left side of her neck.

general medicine, spider bite, injury, tenderness, redness, insect bite, lymphangitis, streaks, spider, neck, bite,

The patient is presenting with what appears to be a possible spider bite, accompanied by lymphangitis, as indicated by the red streaks and erythema. While this could potentially develop into a more serious condition if not treated properly, it is currently being managed with appropriate antibiotics and instructions to monitor symptoms. No immediate life-threatening symptoms, such as fever or intense pain, were reported. Therefore, the situation, although requiring attention, does not pose an immediate high-stakes medical emergency.


Medical Specialty: Hospice - Palliative Care
Sample Name: Hospice Visit - Colon Cancer

HISTORY OF PRESENT ILLNESS:,  History as provided primarily by the patient's daughter, as well as the referring physician revealed an approximately two-year history of colon cancer initially diagnosed when the patient presented with a swelling in his groin.  Approximately one month ago, he presented with abdominal pain and presented to the hospital with transverse colon obstruction.  He had a diverting colostomy performed approximately one month ago.  Approximately two weeks ago, he was admitted to hospital with infection of this with chronically swollen lower extremities and is home now for approximately one week.  He was deemed not to be a candidate for chemotherapy or radiation on the basis of extensive disease, as well as a longstanding history of cirrhosis with esophageal varices.  Additional history includes an enlarged heart and chronic lower extremity edema associated with trauma from his time as an army infantryman in Korea many decades ago.  The patient is alert and lives alone, although the daughter Ruby is in from out of town for several weeks to care for him.  He denies any particular problems with the exception of itch and a site of leakage around his ostomy site.  His appetite is notably improved since discharge from hospital and both he and his daughter believe he has gained a few pounds of weight.  His stooling is regular.  There is no fever.  Of greatest concern to his daughter is a possibility that his colostomy might be reversible and at the recommendation of some of the physicians at the referring hospital, he was to have had a PET scan to assess whether the ostomy is reversible for various reasons, primarily insurance.  The PET scan has not been done and the family is quite concerned about a potential surgical intervention.  The patient denies anxiety or depression and there is no history of same.  He was married for over 50 years and now widowed for nearly 10.  He is a stepfather to five children and he has seven of his own, all in all raising 12 children.  His daughters, Ruby and Camilla are most involved with the patient's care.  The patient is retired, worked in supermarkets for many years when he is very proud of his time as an infantryman in Korea.  He did sustain an injury to the right eye during his service.  He has lots of children, grandchildren, and great-grandchildren and seems to derive great pleasure from them.  He denies spiritual or religious distress.  As to advanced directives, the patient appears not to have any significant advanced directives, written or oral.  Family apparently is working on a "plan.",MEDICATIONS:,  Medications include Toprol 12.5 mg twice daily, Lasix 20 mg daily, ranitidine 75 mg daily, potassium 20 mEq daily, Benadryl 25-50 mg at the hour of sleep as needed, not typically taken and a prescription in the house for Keflex 500 mg q.i.d. for red legs has not yet begun.,PHYSICAL EXAMINATION:,  Examination reveals am alert pale, but thin gentleman with evident wasting.  He is seated and walks without assistance.  His blood pressure is 135/75.  Pulse is 80.  Respiratory rate is 14.  He is afebrile.  Head is without icterus.  Pupils are equal and round.  He has a red dry tongue without leaking mucosal lesions.  There is no jugular venous distention.  The chest has increased AP diameter with good air entry bilaterally.  There is a systolic ejection murmur heard over the entire precordium.  The rate is regular.  The abdomen, he has a right-sided colostomy with a prolapsed bowel.  There is an area of approximately 5 cm x 8 cm of erythema adjacent to the ostomy.  The skin is intact.  The bowel sounds are active.  There is no tenderness in the abdomen and no palpable masses.  Extremities show chronic lymphedema.  The right lower extremity has an 8 cm x 10 cm patch over the anterior shin that is darkened, but not red and not warm.  The distal pulses are intact.  Rectal exam shows no external nor internal hemorrhoids.  No mass is felt and no blood on the gloved finger.  Neurologically, he is alert.  He is oriented times three.  His speech is clear.  His mood appears to be good.  His short-term memory is intact.  There is no focal neurological deficit.,ASSESSMENT:,  A 77-year-old gentleman with apparent widespread intra-abdominal spread of rectal cancer.  Status post bowel obstruction.  Comorbid cirrhosis with esophageal varices.  No history of bleeding.  The patient has had significant clinical and functional decline and I expect that his prognosis would be measured in weeks to months.  The patient lives alone and is currently being very well cared for his daughter from out of town.  She will be leaving in a few weeks.  There is another in-town daughter; however, she works and has a large family.,PLAN:,  I will communicate with the patient's referring physician to ascertain what clinical course and data is available.  A moisture barrier will be applied to his peri-ostomy wound today and we would reassess within 24 hours.  It would be appropriate for a family meeting to be scheduled to review the family and the patient's understanding of his clinical condition and to begin to address an appropriate plan of care for the patient's inevitable decline.,I spoke with Dr. Abc, who informed me that family has in their possession a disc with the CAT scan results.  We will try to ask radiologic colleagues when we obtain the disc to give us a formal reading so that we might better understand the patient's clinical condition and better inform family of his clinical status.
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DESCRIPTION: Hospice visit for 77-year-old gentleman with advanced colon cancer.

hospice - palliative care, hospice, cat scan results, hospice nurse, pet scan, abdominal pain, admitted to hospital, cirrhosis, colon cancer, colon obstruction, esophageal varices, longstanding, moisture barrier, referring physician, health, colon, cancer,

The situation involves a 77-year-old gentleman with advanced colon cancer who is being considered for potential surgical intervention. The patient's cancer prognosis is limited, expected in weeks to months, and he has significant comorbidities, such as cirrhosis with esophageal varices. The family is concerned about the reversibility of the colostomy and upcoming care needs. This is a critical time where discussions around palliative care, advanced directives, and family support are essential. Given these factors, the stakes are relatively high as they pertain to the patient's quality of life and end-of-life care decision-making.


Medical Specialty: Consult - History and Phy.
Sample Name: Well-Child Check - 1

CHIEF COMPLAINT:,  Well-child check.,HISTORY OF PRESENT ILLNESS:,  This is a 12-month-old female here with her mother for a well-child check.  Mother states she has been doing well.  She is concerned about drainage from her left eye.  Mother states she was diagnosed with a blocked tear duct on that side shortly after birth, and normally she has crusted secretions every morning.  She states it is worse when the child gets a cold.  She has been using massaging when she can remember to do so.  The patient is drinking whole milk without problems.  She is using solid foods three times a day.  She sleeps well without problems.  Her bowel movements are regular without problems.  She does not attend daycare.,DEVELOPMENTAL ASSESSMENT:,  Social:  She can feed herself with fingers.  She is comforted by parent’s touch.  She is able to separate and explore.  Fine motor:  She scribbles.  She has a pincer grasp.  She can drink from a cup.  Language:  She says dada.  She says one to two other words and she indicates her wants.  Gross motor:  She can stand alone.  She cruises.  She walks alone.  She stoops and recovers.,PHYSICAL EXAMINATION:,General:  She is alert, in no distress.,Vital signs:  Weight:  25th percentile.  Height:  25th percentile.  Head circumference:  50th percentile.,HEENT:  Normocephalic, atraumatic.  Pupils are equal, round, and reactive to light.  Left eye with watery secretions and crusted lashes.  Conjunctiva is clear.  TMs are clear bilaterally.  Nares are patent.  Mild nasal congestion present.  Oropharynx is clear.,Neck:  Supple.,Lungs:  Clear to auscultation.,Heart:  Regular.  No murmur.,Abdomen:  Soft.  Positive bowel sounds.  No masses.  No hepatosplenomegaly.,GU:  Female external genitalia.,Extremities:  Symmetrical.  Femoral pulses are 2+ bilaterally.  Full range of motion of all extremities.,Neurologic:  Grossly intact.,Skin:  Normal turgor.,Testing:  Hearing and vision assessments grossly normal.,ASSESSMENT:,1.  Well child.,2.  Left lacrimal duct stenosis.,PLAN:,  MMR #1 and Varivax #1 today.  VIS statements given to Mother after discussion.  Evaluation and treatment as needed with Dr. XYZ with respect to the blocked tear duct.  Anticipatory guidance for age.  She is to return to the office in three months.
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DESCRIPTION: Well child - Left lacrimal duct stenosis

consult - history and phy., well-child check, drainage, eye, lacrimal duct stenosis, lacrimal duct, mmr, varivax, vis statements, tear duct, lacrimal, percentile, mother, child,

The situation involves a routine well-child check for a 12-month-old but includes concern about a blocked tear duct, which is a known issue without serious immediate implications. The exam results and developmental milestones are normal, with vaccinations being conducted as per schedule. While blocked tear ducts are common and often resolve without invasive treatment, monitoring and possible further evaluation is advised. However, this is not a high-stakes medical situation.


Medical Specialty: Podiatry
Sample Name: Ankle pain

CHIEF COMPLAINT:,  Ankle pain.,HISTORY OF PRESENT ILLNESS:  ,The patient is a pleasant 17-year-old gentleman who was playing basketball today in gym.  Two hours prior to presentation, he started to fall and someone stepped on his ankle and kind of twisted his right ankle and he cannot bear weight on it now.  It hurts to move or bear weight.  No other injuries noted.  He does not think he has had injuries to his ankle in the past.,PAST MEDICAL HISTORY: , None.,PAST SURGICAL HISTORY: , None.,SOCIAL HISTORY: , He does not drink or smoke.,ALLERGIES: , Unknown.,MEDICATIONS: , Adderall and Accutane.,REVIEW OF SYSTEMS: , As above.  Ten systems reviewed and are negative.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature 97.6, pulse 70, respirations 16, blood pressure 120/63, and pulse oximetry 100% on room air.,GENERAL:
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DESCRIPTION: Acute foot or ankle sprain, possible small fracture.

podiatry, accutane, foot or ankle sprain, ankle sprain, ankle, sprain, splint, fracture,

The situation involves a 17-year-old patient with an acute ankle injury from playing basketball. While the injury causes significant discomfort and the inability to bear weight, it is unlikely to be life-threatening. The potential diagnoses include an ankle sprain or a minor fracture, both of which are generally manageable with standard treatment protocols. Despite this, the impact on daily activities and the need for proper diagnosis could warrant timely medical attention to avoid complications. However, overall, this does not constitute a high-stakes medical emergency.


Medical Specialty: Surgery
Sample Name: Vasectomy - 1

DESCRIPTION:,  The patient was placed in the supine position and was prepped and draped in the usual manner.  The left vas was grasped in between the fingers.  The skin and vas were anesthetized with local anesthesia.  The vas was grasped with an Allis clamp.  Skin was incised and the vas deferens was regrasped with another Allis clamp.  The sheath was incised with a scalpel and elevated using the iris scissors and clamps were used to ligate the vas deferens.  The portion in between the clamps was excised and the ends of the vas were clamped using hemoclips, two in the testicular side and one on the proximal side.  The incision was then inspected for hemostasis and closed with 3-0 chromic catgut interrupted fashion.,A similar procedure was carried out on the right side.  Dry sterile dressings were applied and the patient put on a scrotal supporter.  The procedure was then terminated.
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DESCRIPTION: Normal vasectomy

Normal vasectomy

surgery, vasectomy, allis clamp, catgut, hemoclips, iris scissors, scrotal, scrotal supporter, testicular, vas, vas deferens, vas was grasped, deferens, clampsNOTE,: 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.

A vasectomy is a routine surgical procedure with a high success rate and generally low risk of severe complications. While any surgical procedure carries some level of risk, vasectomies are considered minor surgeries. They are typically done on an outpatient basis, meaning the patient can go home the same day. The stakes are relatively low, as the procedure is elective and not life-threatening. However, as with any medical procedure, it requires precision and proper execution to avoid complications, which is why it's not entirely without stakes.


Medical Specialty: Consult - History and Phy.
Sample Name: Gen Med H&P - 2

HISTORY OF PRESENT ILLNESS: , This is a 43-year-old black man with no apparent past medical history who presented to the emergency room with the chief complaint of weakness, malaise and dyspnea on exertion for approximately one month.  The patient also reports a 15-pound weight loss.  He denies fever, chills and sweats.  He denies cough and diarrhea.  He has mild anorexia.,PAST MEDICAL HISTORY:,  Essentially unremarkable except for chest wall cysts which apparently have been biopsied by a dermatologist in the past, and he was given a benign diagnosis.  He had a recent PPD which was negative in August 1994.,MEDICATIONS: , None.,ALLERGIES: , No known drug allergies.,SOCIAL HISTORY: , He occasionally drinks and is a nonsmoker.  The patient participated in homosexual activity in Haiti during 1982 which he described as "very active." Denies intravenous drug use.  The patient is currently employed.,FAMILY HISTORY:,  Unremarkable.,PHYSICAL EXAMINATION:,GENERAL:  This is a thin, black cachectic man speaking in full sentences with oxygen.,VITAL SIGNS:  Blood pressure 96/56, heart rate 120.  No change with orthostatics.  Temperature 101.6 degrees Fahrenheit.  Respirations 30.,HEENT:  Funduscopic examination normal.  He has oral thrush.,LYMPH:  He has marked adenopathy including right bilateral epitrochlear and posterior cervical nodes.,NECK:  No goiter, no jugular venous distention.,CHEST:  Bilateral basilar crackles, and egophony at the right and left middle lung fields.,HEART:  Regular rate and rhythm, no murmur, rub or gallop.,ABDOMEN:  Soft and nontender.,GENITOURINARY:  Normal.,RECTAL:  Unremarkable.,SKIN:  The patient has multiple, subcutaneous mobile nodules on the chest wall that are nontender.  He has very pale palms., ,LABORATORY AND X-RAY DATA: , Sodium 133, potassium 5.3, BUN 29, creatinine 1.8.  Hemoglobin 14, white count 7100, platelet count 515.  Total protein 10, albumin 3.1, AST 131, ALT 31.  Urinalysis shows 1+ protein, trace blood.  Total bilirubin 2.4, direct bilirubin 0.1.  Arterial blood gases:  pH 7.46, pC02 32, p02 46 on room air.  Electrocardiogram shows normal sinus rhythm.  Chest x-ray shows bilateral alveolar and interstitial infiltrates.,IMPRESSION:,1.  Bilateral pneumonia; suspect atypical pneumonia, rule out Pneumocystis carinii pneumonia and tuberculosis.,2.  Thrush.,3.  Elevated unconjugated bilirubins.,4.  Hepatitis.,5.  Elevated globulin fraction.,6.  Renal insufficiency.,7.  Subcutaneous nodules.,8.  Risky sexual behavior in 1982 in Haiti.,PLAN:,1.  Induced sputum, rule out Pneumocystis carinii pneumonia and tuberculosis.,2.  Begin intravenous Bactrim and erythromycin.,3.  Begin prednisone.,4.  Oxygen.,5.  Nystatin swish and swallow.,6.  Dermatologic biopsy of lesions.,7.  Check HIV and RPR.,8.  Administer Pneumovax, tetanus shot and Heptavax if indicated.
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DESCRIPTION: Weakness, malaise dyspnea on exertion, 15-pound weight loss - Bilateral pneumonia, hepatitis, renal insufficiency,

The case presented is of a 43-year-old man with multiple serious health concerns, including bilateral pneumonia, suspected Pneumocystis carinii pneumonia, thrush, hepatitis, and renal insufficiency, combined with a history of risky sexual behavior and potential diagnosis requiring rapid intervention (e.g., ruling out HIV and tuberculosis). His vital signs indicate significant respiratory distress (pO2 of 46 on room air) and possible sepsis (temperature 101.6ºF, heart rate 120). Management includes urgent diagnostic tests and treatment interventions. Given the combination of potential infectious diseases, deranged laboratory values, presence of opportunistic infection, and systemic involvement, this presents a high-stakes medical situation requiring immediate and comprehensive medical evaluation and treatment to prevent deterioration.


Medical Specialty: Neurosurgery
Sample Name: Anterior Cervical Discectomy & Fusion - 5

PREOPERATIVE DIAGNOSES:  ,1.  Cervical spondylosis C5-C6 greater than C6-C7 (721.0).,2.  Neck pain, progressive (723.1) with right greater than left radiculopathy (723.4).,POSTOPERATIVE DIAGNOSES:  ,1.  Cervical spondylosis C5-C6 greater than C6-C7 (721.0).,2.  Neck pain, progressive (723.1) with right greater than left radiculopathy (723.4), surgical findings confirmed.,PROCEDURES:  ,1.  Anterior cervical discectomy at C5-C6 and C6-C7 for neural decompression (63075, 63076).,2.  Anterior interbody fusion at C5-C6 and C6-C7 (22554, 22585) utilizing Bengal cages x2 (22851).,3.  Anterior instrumentation by Uniplate construction C5, C6, and C7 (22845); with intraoperative x-ray x2.,ANESTHESIA:  ,General.,OPERATIONS: , The patient was brought to the operating room and placed in the supine position where general anesthesia was administered.  Then the anterior aspect of the neck was prepped and draped in the routine sterile fashion.  A linear skin incision was made in the skin fold line from just to the right of the midline to the leading edge of the right sternocleidomastoid muscle and taken sharply to platysma, which was dissected in a subplatysmal manner and then with only blunt dissection, the prevertebral space was encountered and localizing intraoperative x-ray was obtained once cauterized the longus colli muscle bilaterally allowed for the placement along its mesial portion of self-retaining retractors for exposure of tissues.  Prominent anterior osteophytes once identified and compared to preoperative studies were removed at C5-C6 and then at C6-C7 with rongeur, allowing for an annulotomy with an #11 blade through collapsed disc space at C5-6, and even more collapsed at C6-C7.  Gross instability appeared and though minimally at both interspaces and residual disc were removed then with the straight disc forceps providing a discectomy at both levels, sending to Pathology in a routine fashion as disc specimen.  This was sent separately and allowed for residual disc removal of power drill where drilling extended in normal cortical and cancellous elements of the C5 and C6 interspaces and at C6-C7 removing large osteophytes and process, residual osteophytes from which were removed finally with 1 and 2 mm micro Kerrison rongeurs allowing for excision of other hypertrophied ligament posteriorly as well.  This allowed for the bulging into the interspace of the dura, sign of decompressed status, and this was done widely bilaterally to decompress the nerve roots themselves and this was assured by inspection with a double ball dissector as needed.  At no time during the case was there evidence of CSF leakage and hemostasis was well achieved with pledgets of Gelfoam and subsequently removed with copious amounts of antibiotic irrigation as well as Surgifoam.  Once hemostasis well achieved, Bengal cage was filled with the patient's own bone elements of appropriate size, and this was countersunk into position and quite tightly applied it at first C5-C6, then secondly at C6-C7.  These were checked and found to be well applied and further stability was then added by placement nonetheless of a Uniplate of appropriate size.  The appropriate size screws and post-placement x-ray showed well-aligned elements and removal of osteophytes, etc.  The wound was again irrigated with antibiotic solution, inspected, and finally closed in a multiple layered closure by approximation of platysma with interrupted #3-0 Vicryl and the skin with subcuticular stitch of #4-0 Vicryl incorporating a Penrose drain from vertebral space externally through the skin wound and safety pin, and later incorporated itself into sterile bandage.,Once the bandage was placed, the patient was taken, extubated from the operating room to the Recovery area, having in stable, but guarded condition.  At the conclusion of the case, all instrument, needle, and sponge counts were accurate and correct.  There were no intraoperative complications of any type.
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DESCRIPTION: Anterior cervical discectomy at C5-C6 and C6-C7 for neural decompression and anterior interbody fusion at C5-C6 and C6-C7 utilizing Bengal cages x2.  Anterior instrumentation by Uniplate construction C5, C6, and C7 with intraoperative x-ray x2.

neurosurgery, cervical spondylosis, anterior cervical discectomy, anterior instrumentation, annulotomy, kerrison rongeurs, surgifoam, vertebral space, uniplate construction, bengal cages, neural decompression, anterior cervical, cervical discectomy, interbody, anterior, cervical, discectomy

The situation involves neurosurgery, specifically an anterior cervical discectomy and fusion, which is a complex and delicate procedure aimed at relieving pressure on cervical spinal nerves and ensuring stability of the spine. Given that spinal surgery can have significant risks and implications for the patient's mobility and quality of life, this is considered a high-stakes medical scenario. The successful execution of the surgery is critical, as any complications such as infection, nerve damage, or issues with spinal stability can have serious outcomes. Therefore, the complexity, potential risks, and importance of achieving the desired outcome make this a high-stakes situation.


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

Medical Specialty: Surgery
Sample Name: Cardiac Catheterization - 1

INDICATIONS FOR PROCEDURE:, A 51-year-old, obese, white female with positive family history of coronary disease and history of chest radiation for Hodgkin disease 20 years ago with no other identifiable risk factors who presents with an acute myocardial infarction with elevated enzymes. The chest pain occurred early Tuesday morning. She was treated with Plavix, Lovenox, etc., and transferred for coronary angiography and possible PCI. The plan was discussed with the patient and all questions answered.,PROCEDURE NOTE:, Following sterile prep and drape, the right groin and instillation of 1% Xylocaine anesthesia, the right femoral artery was percutaneously entered with a single wall puncture. A 6-French sheath inserted. Selective left and right coronary injections performed using Judkins coronary catheters with a 6-French pigtail catheter used to obtain left ventricle pressures, and a left ventriculography. The left pullback pressure. The catheters withdrawn. Sheath injection. Hemostasis obtained with a 6-French Angio-Seal device. She tolerated the procedure well.,Left ventricular end-diastolic pressure equals 25 mmHg post A wave. No aortic valve or systolic gradient on pullback.,ANGIOGRAPHIC FINDINGS:,I. Left coronary artery: The left main coronary artery is,normal. The left anterior descending extends to the apex and has only minor luminal irregularities within the midportion of the vessel. Normal diagonal branches. Normal septal perforator branches. The left circumflex is a nondominant vessel with only minor irregularities with normal obtuse marginal branches.,II. Right coronary artery: The proximal right coronary artery has a focal calcification. There is minor plaque with luminal irregularity in the proximal and midportion of the vessel with no narrowing greater than 10 to 20% at most. The right coronary artery is a dominant system which gives off normal posterior,descending and posterior lateral branches. TIMI 3 flow is present.,III. Left ventriculogram: The left ventricle is slightly enlarged with normal contraction of the base, but, with wall motion abnormality involving the anteroapical and inferoapical left ventricle with hypokinesis within the apical portion. Ejection fraction estimated 40%, 1+ mitral regurgitation (echocardiogram ordered).,DISCUSSION:, Recent inferoapical mild myocardial infarction by left ventriculography and cardiac enzymes with elevated left ventricular end-diastolic pressure post A wave, but, only minor residual coronary artery plaque with calcification proximal right coronary artery.,PLAN:, Medical treatment is contemplated, including ACE inhibitor, a beta blocker, aspirin, Plavix, nitrates. An echocardiogram is ordered to exclude apical left ventricular thrombus and to further assess ejection fraction.
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DESCRIPTION: Cardiac Catheterization - An obese female with a family history of coronary disease and history of chest radiation for Hodgkin disease, presents with an acute myocardial infarction with elevated enzymes.

surgery, cardiac catheterization, hodgkin disease, beta blocker, coronary angiography, coronary artery, coronary disease, elevated enzymes, inferoapical, myocardial infarction, ventriculogram, ventriculography, acute myocardial infarction, proximal right coronary, diastolic pressure, ejection fraction, coronary, echocardiogram, cardiac, catheterization, myocardial, enzymes, infarction, artery

The situation involves a 51-year-old patient undergoing cardiac catheterization following an acute myocardial infarction, which is a serious medical condition. The procedure and the patient's health history, including past chest radiation and obesity, increase the risk factors for complications during or after the procedure. The stakes are high due to the possibility of life-threatening complications or poor outcomes without proper intervention and treatment.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Heart Catheterization, Ventriculography, & Angiography - 1

PROCEDURE:,  Left heart catheterization, left ventriculography, coronary angiography, and successful stenting of tight lesion in the distal circumflex and moderately tight lesion in the mid right coronary artery.  This gentleman has had a non-Q-wave, troponin-positive myocardial infarction, complicated by ventricular fibrillation.,PROCEDURE DETAILS:,  The patient was brought to the catheterization lab, the chart was reviewed, and informed consent was obtained.  Right groin was prepped and draped sterilely and infiltrated 2% Xylocaine.  Using the Seldinger technique, a #6-French sheath was placed in the right femoral artery.  ACT was checked and was low.  Additional heparin was given.  A #6-French pigtail catheter was passed.  Left ventriculography was performed.  The catheter was exchanged for a #6-French JL4 catheter.  Nitroglycerin was given in the left main.  Left coronary angiography was performed.  The catheter was exchanged for a #6-French __________ coronary catheter.  Nitroglycerin was given in the right main, and right coronary angiography was performed.  Films were closely reviewed, and it was felt that he had a significant lesion in the RCA and the distal left circumflex is basically an OM.  Considering his age and his course, it was elected to stent both these lesions.  ReoPro was started, and the catheter was exchanged for a #6-French JR4 guide.  ReoPro was given in the RCA to prevent no reflow.  A 0.014 Universal wire was passed.  The lesion was measured.  A 4.5 x 18-mm stent was passed and deployed to moderate pressures with an excellent result.  The catheter was removed and exchanged for a #6-French JL4 guide.  The same wire was passed down the circumflex and the lesion measured.  A 2.75 x 15-mm stent was deployed to a moderate pressure with an excellent result.  Plavix was given.  The catheter was removed and sheath was in place.  The results were explained to the patient and his wife.,FINDINGS,1.  Hemodynamics.  Please  see attached sheet for details.  ED was 20.  There is no gradient across the aortic valve.,2.  Left ventriculography revealed septum upper limits of normal size with borderline normal LV systolic function with borderline normal wall motion, in which there is a question of  diffuse, very minimal global hypokinesis.  There is mild MR noted.,3.  Coronary angiography.,a.  Left main normal.,b.  LAD.  Some very minimal luminal irregularities.  There is a 1st diagonal which has a branch that is 1.5 mm with a proximal 50% narrowing.,c.  Left circumflex is basically a marginal branch, in which distally there was a long 98% lesion.,d.  The RCA is large dominant and has a mid somewhat long 70% lesion.,4.  Stenting.,a.  The RCA revealed a lesion that went from 70% to a -5%.,B.  The circumflex went from 95% to -5%.,CONCLUSION,1.  Decreased left ventricular compliance.,2.  Borderline normal overall ejection fraction with mild mitral regurgitation.,3.  Triple-vessel coronary artery disease with a borderline lesion in a very small branch of the 1st diagonal and significant lesions in the mid dominant right coronary artery and the distal circumflex, which is basically old.,4.  Successful stenting of the right coronary artery and the circumflex.,RECOMMENDATION: , ReoPro/stent protocol, Plavix for at least 9 months, aggressive control of risk factors.  I have ordered Zocor and a fasting lipid panel.,AICD will be considered, realizing when this gentleman becomes ischemic he is at high risk for fibrillating.
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DESCRIPTION: Left heart catheterization, left ventriculography, coronary angiography, and successful stenting of tight lesion in the distal circumflex and moderately tight lesion in the mid right coronary artery.

cardiovascular / pulmonary, heart catheterization, ventriculography, coronary angiography, stenting, distal circumflex, coronary artery, coronary, lesion, catheterization, cardiac, angiography, heart, rca, artery, circumflex,

The situation involves a detailed cardiovascular procedure that includes heart catheterization, ventriculography, angiography, and stenting, following a myocardial infarction complicated by ventricular fibrillation. This highlights a critical and potentially life-threatening condition, requiring careful management and follow-up. Successful stenting was achieved, which suggests that the immediate threat has been mitigated, but the recommendations also indicate ongoing risk due to the patient's coronary artery disease. Therefore, the stakes are high since the outcome directly impacts the patient's health and survival.


Medical Specialty: Consult - History and Phy.
Sample Name: Well-Child Check - 5

SUBJECTIVE:,  The patient presents with Mom for a first visit to our office for a well-child check with concern of some spitting up quite a bit.  Mom wants to make sure that this is normal.  The patient is nursing well every two to three hours.  She does have some spitting up on occasion.  It has happened two or three times with some curdled appearance x 1.  No projectile in nature, nonbilious.  Normal voiding and stooling pattern.  Growth and Development:  Denver II normal, passing all developmental milestones per age.  See Denver II form in the chart.,PAST MEDICAL HISTORY:,  Mom reports uncomplicated pregnancy with prenatal care provided by Dr. XYZ in Wichita, Kansas.  Delivery after induction secondary to postdate at St. Joseph Hospital.  Infant delivered by SVD with birth weight of 6 pounds 13 ounce.  Length of 19 inches.  Did well after delivery and dismissed to home with Mom.  Received hepatitis B #1 prior to dismissal.  No other hospitalizations.  No surgeries.  No known medical allergies.  No medications.  Mom has tried Mylicon drops on occasion.,FAMILY HISTORY: , Significant for cardiovascular disease, hypertension, diabetes mellitus and thyroid problems in maternal and paternal grandparents.  Healthy Mother, Father.  There is also history of breast, colon and ovarian cancer on the maternal side of the family, her grandmother who is present at visit today.  There is history of asthma in the patient's father.,SOCIAL HISTORY:,  The patient lives at home with 23-year-old mother, who is a homemaker and 24-year-old father, John, who is a supervisor at Excel.  The family lives in Bentley, Kansas.  No smoking in the home.  Family does have one pet cat.,REVIEW OF SYSTEMS:,  As per HPI, otherwise, negative.,OBJECTIVE:,  Weight:  7 pounds 12 ounces.  Height:  21 inches.  Head circumference:  35 cm.  Temperature:  97.2 degrees.,General:  Well-developed, well-nourished, cooperative, alert, interactive 2-week-old white female in no acute distress.,HEENT:  Atraumatic, normocephalic.  Anterior fontanel is soft and flat.  Pupils are equal, round and reactive.  Sclerae clear.  Red reflexes present bilaterally.  TMs are clear bilaterally.  Oropharynx:  Mucous membranes are moist and pink.,Neck:  Supple, no lymphadenopathy.,Chest:  Clear to auscultation bilaterally.  No wheeze or crackles.  Good air exchange.,Cardiovascular:  Regular rate and rhythm.  No murmur.  Good pulses bilaterally.,Abdomen:  Soft, nontender, nondistended.  Positive bowel sounds.  No mass nor organomegaly.,Genitourinary:  Tanner I female genitalia.  Femoral pulses are equal bilaterally.  No rash.,Extremities:  Full range of motion.  No cyanosis, clubbing or edema.  Negative Ortolani or Barlow maneuver.,Back:  Straight.  No scoliosis.,Integument:  Warm, dry and pink without lesions.,Neurologic:  Alert.  Good muscle tone and strength.,ASSESSMENT/PLAN:,1.  Well 2-week-old white female.,2.  Anticipatory guidelines for growth, diet, development, safety issues as well as immunizations and visitation schedule.  Gave 2-week well-child check handout and American Academy of Pediatrics book Birth to 5 years to Mom and family.,3.  Call the office or on-call physician if the patient has fever, feeding problems or breathing problems.  Otherwise plan to recheck at 1-month of age.
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DESCRIPTION: A well-child check with concern of some spitting up quite a bit.

consult - history and phy., well-child check, denver ii, child check, growth, development, denver, cardiovascular, maternal, mother, spitting, father, child, check, asthma, family, mom,

The situation involves a well-child check-up, which is a routine examination for a healthy infant. The only concern raised is occasional spitting up, which is common and normal in infants unless it is accompanied by more serious symptoms like projectile vomiting or failure to thrive. The child's overall health indicators, as noted in the findings, are normal. Therefore, this does not represent a high-stakes situation as there are no immediate risks to the child's health. The practitioners have provided guidance and set a schedule for follow-up, indicating that the current concerns are standard and manageable.


Medical Specialty: Surgery
Sample Name: Orchiopexy & Hernia Repair - 1

PREOPERATIVE DIAGNOSIS: , Right undescended testis (ectopic position).,POSTOPERATIVE DIAGNOSES:,  Right undescended testis (ectopic position), right inguinal hernia.,PROCEDURES: , Right orchiopexy and right inguinal hernia repair.,ANESTHESIA:,  General inhalational anesthetic with caudal block.,FLUIDS RECEIVED:  ,100 mL of crystalloids.,ESTIMATED BLOOD LOSS: , Less than 5 mL.,SPECIMENS:,  No tissues sent to pathology.,TUBES AND DRAINS: , No tubes or drains were used.,INDICATIONS FOR OPERATION:  ,The patient is an almost 4-year-old boy with an undescended testis on the right; plan is for repair.,DESCRIPTION OF OPERATION:  ,The patient was taken to the operating room; surgical consent, operative site, and patient identification were verified.  Once he was anesthetized, a caudal block was placed.  He was then placed in the supine position and sterilely prepped and draped.  Since the testis was in the ectopic position, we did an upper curvilinear scrotal incision with a 15-blade knife and further extended it with electrocautery.  Electrocautery was also used for hemostasis.  A subdartos pouch was then created with a curved tenotomy scissors.  The tunica vaginalis was grasped with a curved mosquito clamp and then dissected from its gubernacular attachments.  As we were dissecting it, we then found the testis itself into the sac, and we opened the sac, and it was found to be slightly atrophic about 12 mm in length and had a type III epididymal attachment, not being attached to the top.  We then dissected the hernia sac off of the testis __________ some traction using the straight Joseph scissors and straight and curved mosquito clamps.  Once this was dissected off, we then twisted it upon itself, and then dissected it down towards the external ring, but on traction.  We then twisted it upon itself, suture ligated it with 3-0 Vicryl and released it, allowing it to spring back into the canal.  Once this was done, we then had adequate length of the testis into the scrotal sac.  Using a curved mosquito clamp, we grasped the base of the scrotum internally, and using the subcutaneous tissue, we tacked it to the base of the testis using a 4-0 chromic suture.  The testis was then placed into the scrotum in the proper orientation.  The upper aspect of the pouch was closed with a pursestring suture of 4-0 chromic.  The scrotal skin and dartos were then closed with subcutaneous closure of 4-0 chromic, and Dermabond tissue adhesive was used on the incision.  IV Toradol was given.  Both testes were well descended in the scrotum at the end of the procedure.
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DESCRIPTION: Right orchiopexy and right inguinal hernia repair.

surgery, ectopic position, inguinal hernia, inguinal hernia repair, hernia sac, tunica vaginalis, gubernacular attachments, testis ectopic position, curved mosquito clamp, caudal block, hernia repair, undescended testis, orchiopexy, dissected, hernia, inguinal, testis,

The situation involves a surgical procedure on a young child to address an undescended testis and inguinal hernia. While surgeries inherently carry certain risks, this is a relatively common procedure. However, due to the age of the patient and the use of general anesthesia, the situation has moderate stakes. Any surgery carries the possibility of complications, although the estimated blood loss is minimal, and the procedure seems to have been executed successfully without immediate complications.


Medical Specialty: Consult - History and Phy.
Sample Name: Speech Therapy Evaluation - 1

DIAGNOSIS: , Status post brain tumor with removal.,SUBJECTIVE:  ,The patient is a 64-year-old female with previous medical history of breast cancer that has metastasized to her lung, liver, spleen, and brain, status post radiation therapy.  The patient stated that on 10/24/08 she had a brain tumor removed with subsequent left-sided weakness.  The patient was readmitted to ABC Hospital on 12/05/08 and was found to have massive swelling in the brain and a second surgery was performed to reduce the swelling.  The patient remained at the acute rehab at ABC until she was discharged home on 01/05/09.  The patient did receive skilled speech therapy while in the acute rehab, which focused on higher level cognitive and linguistic skills such as attention, memory, mental flexibility, and improvement of her executive function.  The patient also complains of difficulty with word retrieval and slurring of speech.  The patient denies any difficulty with swallowing at this time.,OBJECTIVE:  ,Portions of the cognitive linguistic quick test was administered.  An oral mechanism exam was performed.  A motor speech protocol was completed.,The cognitive linguistic subtests of recalling personal facts, symbol cancellation, confrontational naming, clock drawing, story retelling, generative naming, design and memory, and completion of mazes was administered.,The patient was 100% accurate with recalling personal facts, completion of the symbol cancellation tasks, and with confrontational naming.  She had no difficulty with the clock drawing task; however, she has considerable hand tremors, which makes writing difficult.  In the storytelling task, she scored within normal limits.  She was also within normal limits for generative naming.  She did have difficulty with the design, memory, and mazes subtests.  She was unable to complete the second maze during the allotted time.  The design generation subtest was also completed.  She was able to draw four unique designs, and toward the end of the tasks was no longer able to recall the stated direction.,ORAL MECHANISM EXAMINATION:,  The patient has mild left facial droop with decreased nasolabial fold.  Tongue is at midline, and lingual range of motion and strength are within functional limit.  The patient does complain of biting her tongue on occasion, but denied biting the inside of her cheeks.  Her AMRs are judged to be within functional limit.  Her rate of speech is decreased with a monotonous vocal quality.  The decreased rate may be a compensation for decreased word retrieval ability.  The patient's speech is judged to be 100% intelligible without background noise.,DIAGNOSTIC IMPRESSION:  ,The patient has mild cognitive linguistic deficits in the areas of higher level cognitive function seen in mental flexibility, memory, and executive function.,PLAN OF CARE:,  Outpatient skilled speech therapy two times a week for four weeks to include cognitive linguistic treatment.,SHORT-TERM GOALS (THREE WEEKS):,1.  The patient will complete deductive reasoning and mental flexibility tasks with greater than 90% accuracy, independently.,2.  The patient will complete perspective memory test with 100% accuracy using compensatory strategy.,3.  The patient will complete visual perceptual activities, which focus on scanning, flexibility, and problem solving with greater than 90% accuracy with minimal cueing.,4.  The patient will listen to and/or read a lengthy narrative and be able to recall at least 6 details after a 15-minute delay, independently.,PATIENT'S GOAL:  ,To improve functional independence and cognitive abilities.,LONG-TERM GOAL (FOUR WEEKS):  ,Functional cognitive linguistic abilities to improve safety and independence at home and to decrease burden of care on caregiver.,
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DESCRIPTION: Status post brain tumor with removal.  The patient did receive skilled speech therapy while in the acute rehab, which focused on higher level cognitive and linguistic skills such as attention, memory, mental flexibility, and improvement of her executive function.

consult - history and phy., linguistic skills, memory, mental flexibility, deductive reasoning, skilled speech therapy, speech therapy, cognitive linguistic, therapy, linguistic, speech, cognitive,

The situation involves a 64-year-old female who has undergone significant medical treatment, including brain tumor removal and radiation therapy, leading to cognitive and speech issues requiring speech therapy. The high-stakes element is related to the patient's quality of life, safety, and independence, as cognitive deficits can impact daily functioning and the ability to manage personal care. While it is not immediately life-threatening, the effectiveness of the rehabilitation process is crucial for her long-term well-being and reducing caregiver burden.


Medical Specialty: Orthopedic
Sample Name: MRI Shoulder - 4

EXAM:,MRI LEFT SHOULDER,CLINICAL:,This is a 69-year-old male with pain in the shoulder. Evaluate for rotator cuff tear.,FINDINGS:,Examination was performed on 9/1/05.,There is marked supraspinatus tendinosis and extensive tearing of the substance of the tendon and articular surface, extending into the myotendinous junction as well. There is still a small rim of tendon along the bursal surface, although there may be a small tear at the level of the rotator interval. There is no retracted tendon or muscular atrophy (series #6 images #6-17).,Normal infraspinatus tendon.,There is subscapularis tendinosis with fraying and partial tearing of the superior most fibers extending to the level of the rotator interval (series #9 images #8-13; series #3 images #8-14). There is no complete tear, gap or fiber retraction and there is no muscular atrophy.,There is tendinosis and superficial tearing of the long biceps tendon within the bicipital groove, and there is high grade (near complete) partial tearing of the intracapsular portion of the tendon. The biceps anchor is intact. There are degenerative changes in the greater tuberosity of the humerus but there is no fracture or subluxation.,There is degeneration of the superior labrum and there is a small nondisplaced tear in the posterior superior labrum at the one to two o’clock position (series #6 images #12-14; series #3 images #8-10; series #9 images #5-8). There is a small sublabral foramen at the eleven o’clock position (series #9 image #6). There is no osseous Bankart lesion.,Normal superior, middle and inferior glenohumeral ligaments.,There is hypertrophic osteoarthropathy of the acromioclavicular joint with narrowing of the subacromial space and flattening of the superior surface of the supraspinatus musculotendinous junction, which in the appropriate clinical setting is an MRI manifestation of an impinging lesion (series #8 images #3-12).,Normal coracoacromial, coracohumeral and coracoclavicular ligaments. There is minimal fluid within the glenohumeral joint. There is no atrophy of the deltoid muscle.,IMPRESSION:,  There is extensive supraspinatus tendinosis and partial tearing as described. There is no retracted tendon or muscular atrophy, but there may be a small tear along the anterior edge of the tendon at the level of the rotator interval, and this associated partial tearing of the superior most fibers of the subscapularis tendon.  There is also a high-grade partial tear of the long biceps tendon as it courses under the transverse humeral ligament. There is no evidence of a complete tear or retracted tendon. Small nondisplaced posterior superior labral tear. Outlet narrowing from the acromioclavicular joint, which in the appropriate clinical setting is an MRI manifestation of an impinging lesion.
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DESCRIPTION: A 69-year-old male with pain in the shoulder. Evaluate for rotator cuff tear.

orthopedic, level of the rotator, impinging lesion, rotator interval, retracted tendon, muscular atrophy, partial tearing, tendon, mri, shoulder, rotator, superior, tear,

The situation involves analyzing an MRI to determine the extent of a suspected rotator cuff tear and other associated shoulder conditions in an elderly patient. While it is not a life-threatening situation, it is significant for the patient's quality of life, as shoulder pain and impaired function can greatly affect daily activities. The patient could require surgical intervention or extensive physical therapy based on these findings, indicating moderate stakes in deciding the treatment plan.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Fiberoptic Flexible Bronchoscopy

PREOPERATIVE DIAGNOSES:,1.  Right hyoid mass, rule out carcinomatosis.,2.  Weight loss.,3.  Chronic obstructive pulmonary disease.,POSTOPERATIVE DIAGNOSES:,1.  Right hyoid mass, rule out carcinomatosis.,2.  Weight loss.,3.  Chronic obstructive pulmonary disease.,4.  Changes consistent with acute and chronic bronchitis.,5.  Severe mucosal irregularity with endobronchial narrowing of the right middle and lower lobes.,6.  Left vocal cord irregularity.,PROCEDURE PERFORMED:  ,Fiberoptic flexible bronchoscopy with lavage, brushings, and endobronchial mucosal biopsies of the right bronchus intermedius/right lower lobe.,ANESTHESIA: , Demerol 50 mg with Versed 3 mg as well as topical cocaine and lidocaine solution.,LOCATION OF PROCEDURE: , Endoscopy suite #4.,After informed consent was obtained and following the review of the procedure including procedure as well as possible risks and complications were explained and consent was previously obtained, the patient was sedated with the above stated medication and the patient was continuously monitored on pulse oximetry, noninvasive blood pressure, and EKG monitoring.  Prior to starting the procedure, the patient was noted to have a baseline oxygen saturation of 86% on room air.  Subsequently, she was given a bronchodilator treatment with Atrovent and albuterol and subsequent saturation increased to approximately 90% to 91% on room air.,The patient was placed on a supplemental oxygen as the patient was sedated with above-stated medication.  As this occurred, the bronchoscope was inserted into the right naris with good visualization of the nasopharynx and oropharynx.  The cords were noted to oppose bilaterally on phonation.  There was some slight mucosal irregularity noted on the vocal cord on the left side.  Additional topical lidocaine was instilled on the vocal cords, at which point the bronchoscope was introduced into the trachea, which was midline in nature.  The bronchoscope was then advanced to the distal trachea and additional lidocaine was instilled.  At this time, the bronchoscope was further advanced through the main stem and additional lidocaine was instilled.  Bronchoscope was then further advanced into the right upper lobe, which revealed no evidence of any endobronchial lesion.  The mucosa was diffusely friable throughout.  Bronchoscope was then slowly withdrawn into the right main stem and additional lidocaine was instilled.  At this point, the bronchoscope was then advanced to the right bronchus intermedius.  At this time, it was noted that there was severe mucosal irregularities of nodular in appearance significantly narrowing the right lower lobe and right middle lobe opening.  The mucosal area throughout this region was severely friable.  Additional lidocaine was instilled as well as topical epinephrine.  At this time, bronchoscope was maintained in this region and endobronchial biopsies were performed.  At the initial attempt of inserting biopsy forceps, some resistance was noted within the proximal channel at this time making advancement of the biopsy forceps out of the proximal channel impossible.  So the biopsy forceps was withdrawn and the bronchoscope was completely withdrawn and new bronchoscope was then utilized.  At this time, bronchoscope was then reinserted into the right naris and subsequently advanced to the vocal cords into the right bronchus intermedius without difficulty.  At this time, the biopsy forceps were easily passed and visualized in the right bronchus intermedius.  At this time, multiple mucosal biopsies were performed with some mild oozing noted.  Several aliquots of normal saline lavage followed.  After completion of multiple biopsies there was good hemostasis.  Cytology flushing was also performed in this region and subsequently several aliquots of additional normal saline lavage was followed.  Bronchoscope was unable to be passed distally to the base of the segment of the right lower lobe or distal to the further visualized endobronchial anatomy of the right middle lobe subsegments.  The bronchoscope was then withdrawn to the distal trachea.,At this time, bronchoscope was then advanced to the left main stem.  Additional lidocaine was instilled.  The bronchoscope was advanced to the left upper and lower lobe subsegments.  There was no endobronchial lesion visualized.  There is mild diffuse erythema and fibromucosa was noted throughout.  No endobronchial lesion was visualized in the left bronchial system.  The bronchoscope was then subsequently further withdrawn to the distal trachea and readvanced into the right bronchial system.  At this time, bronchoscope was readvanced into the right bronchus intermedius and additional aliquots of normal saline lavage until cleared.  There is no gross bleeding evidenced at this time or diffuse mucosal erythema and edema present throughout.  The bronchoscope was subsequently withdrawn and the patient was sent to recovery room.  During the bronchoscopy, the patient noted ________ have desaturation and required increasing FiO2 with subsequent increased saturation to 93% to 94%.  The patient remained at this level of saturation or greater throughout the remaining of the procedure.,The patient postprocedure relates having some intermittent hemoptysis prior to the procedure as well as moderate exertional dyspnea.  This was confirmed by her daughter and mother who were also present at the bedside postprocedure.  The patient did receive a nebulizer bronchodilator treatment immediately prebronchoscopy and postprocedure as well.  The patient also admitted to continued smoking in spite of all of the above.  The patient was extensively counseled regarding the continued smoking especially with her present symptoms.  She was advised regarding smoking cessation.  The patient was also placed on a prescription of prednisone 2 mg tablets starting at 40 mg a day decreasing every three days to continue to wean off.  The patient was also administered Solu-Medrol 60 mg IV x1 in recovery room.  There was no significant bronchospastic component noted, although because of the severity of the mucosal edema, erythema, and her complaints, short course of steroids will be instituted.  The patient was also advised to refrain from using any aspirin or other nonsteroidal anti-inflammatory medication because of her hemoptysis.  At this time, the patient was also advised that if hemoptysis were to continue or worsen or develop progressive dyspnea, to either contact myself, , or return to ABCD Emergency Room for evaluation of possible admission.  However, the above was reviewed with the patient in great detail as well as with her daughter and mother who were at the bedsite at this time as well.
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DESCRIPTION: Fiberoptic flexible bronchoscopy with lavage, brushings, and endobronchial mucosal biopsies of the right bronchus intermedius/right lower lobe.  Right hyoid mass, rule out carcinomatosis.  Chronic obstructive pulmonary disease.  Changes consistent with acute and chronic bronchitis.

cardiovascular / pulmonary, carcinomatosis, chronic obstructive pulmonary disease, fiberoptic flexible bronchoscopy, lavage, brushings, endobronchial mucosal biopsies, mucosal, bronchoscope, atrovent, topical, fiberoptic, hemoptysis, bronchoscopy, endobronchial, oropharynx

The situation involves diagnosing and potentially treating a patient with serious respiratory and potential cancer-related issues. The procedure and its findings could significantly impact the patient's treatment plan and prognosis. Conditions like COPD, potential carcinoma, and severe mucosal irregularity increase risk factors during medical procedures. Additionally, the presence of severe mucosal irregularities and potential cancer make this a high-stakes medical case where outcomes can severely impact the patient's quality of life and survival. The procedure involves sedation and biopsies, which come with inherent risks that need careful management.


Medical Specialty: ENT - Otolaryngology
Sample Name: Neck Dissection

PREOPERATIVE DIAGNOSIS: , Metastatic papillary cancer, left neck.,POSTOPERATIVE DIAGNOSIS: , Metastatic papillary cancer, left neck.,OPERATION PERFORMED: , Left neck dissection.,ANESTHESIA:  ,General endotracheal.,INDICATIONS: , The patient is a very nice gentleman, who has had thyroid cancer, papillary cell type, removed with a total thyroidectomy and then subsequently recurrent disease was removed with a paratracheal dissection.  He now has evidence of lesion in the left mid neck and the left superior neck on ultrasound, which are suspicious for recurrent cancer.  Left neck dissection is indicated.,DESCRIPTION OF OPERATION: , The patient was placed on the operating room table in the supine position.  After adequate general endotracheal anesthesia was administered, the table was then turned.  A shoulder roll placed under the shoulders and the face was placed in an extended fashion.  The left neck, chest, and face were prepped with Betadine and draped in a sterile fashion.  A hockey stick skin incision was performed, extending a previous incision line superiorly towards the mastoid cortex through skin, subcutaneous tissue and platysma with Bovie electrocautery on cut mode.  Subplatysmal superior and inferior flaps were raised.  The dissection was left lateral neck dissection encompassing zones 1, 2A, 2B, 3, and the superior portion of 4.  The sternocleidomastoid muscle was unwrapped at its fascial attachment and this was taken back posterior to the XI cranial nerve into the superior posterior most triangle of the neck.  This was carried forward off of the deep rooted muscles including the splenius capitis and anterior and middle scalenes taken medially off of these muscles including the fascia of the muscles, stripped from the carotid artery, the X cranial nerve, the internal jugular vein and then carried anteriorly to the lateral most extent of the dissection previously done by Dr. X in the paratracheal region.  The submandibular gland was removed as well.  The X, XI, and XII cranial nerves were preserved.  The internal jugular vein and carotid artery were preserved as well.  Copious irrigation of the wound bed showed no identifiable bleeding at the termination of the procedure.  There were two obviously positive nodes in this neck dissection.  One was left medial neck just lateral to the previous tracheal dissection and one was in the mid region of zone 2.  A #10 flat fluted Blake drain was placed through a separate stab incision and it was secured to the skin with a 2-0 silk ligature.  The wound was closed in layers using a 3-0 Vicryl in a buried knot interrupted fashion for the subcutaneous tissue and the skin was closed with staples.  A fluff and Kling pressure dressing was then applied.  The patient was extubated in the operating room, brought to the recovery room in satisfactory condition.  There were no intraoperative complications.
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DESCRIPTION: Left neck dissection.   Metastatic papillary cancer, left neck.  The patient had thyroid cancer, papillary cell type, removed with a total thyroidectomy and then subsequently recurrent disease was removed with a paratracheal dissection.

ent - otolaryngology, metastatic papillary cancer, thyroidectomy, thyroid cancer, papillary cell type, dissection, neck, metastatic, paratracheal, papillary, cancer

The situation involves a surgical procedure for metastatic papillary cancer, with the patient having a history of thyroid cancer and undergoing complex surgical interventions, including a total thyroidectomy and neck dissection. The risk of surgery, potential complications, and the management of recurrent cancer elevate the stakes. Surgical precision is crucial to preserve nerves and major blood vessels, as well as to ensure complete removal of cancerous tissues. These factors make the situation high-stakes in a medical context.