Medical Specialty: Surgery
Sample Name: Colonoscopy & Esophagogastroduodenoscopy

PREOPERATIVE DIAGNOSES:,1.  Hematochezia.,2.  Refractory dyspepsia.,POSTOPERATIVE DIAGNOSES:,1.  Colonic polyps at 35 cm and 15 cm.,2.  Diverticulosis coli.,2.  Acute and chronic gastritis.,PROCEDURE PERFORMED:,1.  Colonoscopy to cecum with snare polypectomy.,2.  Esophagogastroduodenoscopy with biopsies.,INDICATIONS FOR PROCEDURES:  ,This is a 43-year-old white male who presents as an outpatient to the General Surgery Service with hematochezia with no explainable source at the anal verge.  He also had refractory dyspepsia despite b.i.d., Nexium therapy.  The patient does use alcohol and tobacco.  The patient gave informed consent for the procedure.,GROSS FINDINGS: , At the time of colonoscopy, the entire length of colon was visualized.  The patient was found to have a sigmoid diverticulosis.  He also was found to have some colonic polyps at 35 cm and 15 cm.  The polyps were large enough to be treated with snare cautery technique.  The polyps were achieved and submitted to pathology.  EGD did confirm acute and chronic gastritis.  The biopsies were performed for H&E and CLO testing.  The patient had no evidence of distal esophagitis or ulcers.  No mass lesions were seen.,PROCEDURE:  ,The patient was taken to the Endoscopy Suite with the heart and lungs examination unremarkable.  The vital signs were monitored and found to be stable throughout the procedure.  The patient was placed in the left lateral position where intravenous Demerol and Versed were given in a titrated fashion.,The video Olympus colonoscope was advanced per anus and without difficulty to the level of cecum.  Photographic documentation of the diverticulosis and polyps were obtained.  The patient's polyps were removed in a similar fashion, each removed with snare cautery.  The polyps were encircled at their stalk.  Increasing the tension and cautery was applied as coagulation and cutting blunt mode, 15/15 was utilized.  Good blanching was seen.  The polyp was retrieved with the suction port of the scope.  The patient was re-scoped to the polyp levels to confirm that there was no evidence of perforation or bleeding at the polypectomy site.  Diverticulosis coli was also noted.  With colonoscopy completed, the patient was then turned for EGD.  The oropharynx was previously anesthetized with Cetacaine spray and a biteblock was placed.  Video Olympus GIF gastroscope model was inserted per os and advanced without difficulty through the hypopharynx.  The esophagus revealed a GE junction at 39 cm.  The GE junction was grossly within normal limits.  The stomach was entered and distended with air.  Acute and chronic gastritis features as stated were appreciated.  The pylorus was traversed with normal duodenum.  The stomach was again reentered.  Retroflex maneuver of the scope confirmed that there was no evidence of hiatal hernia.  There were no ulcers or mass lesions seen.  The patient had biopsy performed of the antrum for H&E and CLO testing.  There was no evidence of untoward bleeding at biopsy sites.  Insufflated air was removed with withdrawal of the scope.  The patient will be placed on a reflux diet, given instruction and information on Nexium usage.  Additional recommendations will follow pending biopsy results.  He is to also abstain from alcohol and tobacco.  He will require follow-up colonoscopy again in three years for polyp disease.
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DESCRIPTION: Colonoscopy to cecum with snare polypectomy and esophagogastroduodenoscopy with biopsies.  Hematochezia, refractory dyspepsia, colonic polyps at 35 cm and 15 cm, diverticulosis coli, and acute and chronic gastritis.

surgery, endoscopy, olympus colonoscope, snare polypectomy, ge junction, refractory dyspepsia, colonic polyps, diverticulosis coli, chronic gastritis, esophagogastroduodenoscopy, snare, biopsies, dyspepsia, gastritis, diverticulosis, polypectomy, colonoscopy, hematochezia, polyps

This medical situation involves a colonoscopy and esophagogastroduodenoscopy for a patient presenting with hematochezia and refractory dyspepsia. The procedures revealed colonic polyps, diverticulosis, and gastritis, all of which are managed using standard techniques such as polypectomy and biopsies. While the findings themselves, like polyps and gastritis, can indicate more serious conditions, the patient appears stable and procedures were conducted without complications. The need for follow-up suggests moderate long-term monitoring rather than immediate intervention. The stakes are therefore moderate given the potential implications of the findings but managed appropriately in a clinical setting.


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

Medical Specialty: Neurosurgery
Sample Name: Laminotomy, Facetectomy & Foraminotomy

PREOPERATIVE DIAGNOSES: , Right lumbosacral radiculopathy secondary to lumbar spondylolysis.,POSTOPERATIVE DIAGNOSES: , Right lumbosacral radiculopathy secondary to lumbar spondylolysis.,OPERATION PERFORMED:,1.  Right L4 and L5 transpedicular decompression of distal right L4 and L5 nerve roots.,2.  Right L4-L5 and right L5-S1 laminotomies, medial facetectomies, and foraminotomies, decompression of right L5 and S1 nerve roots.,3.  Right L4-S1 posterolateral fusion with local bone graft.,4.  Left L4 through S1 segmental pedicle screw instrumentation.,5.  Preparation harvesting of local bone graft.,ANESTHESIA: , General endotracheal.,PREPARATION:,  Povidone-iodine.,INDICATION: , This is a gentleman with right-sided lumbosacral radiculopathy, MRI disclosed and lateral recess stenosis at the L4-5, L5-S1 foraminal narrowing in L4 and L5 roots.  The patient was felt to be a candidate for decompression stabilization pulling distraction between the screws to relieve radicular pain.  The patient understood major risks and complications such as death and paralysis seemingly rare, main concern is a 10 to 15% of failure rate to respond to surgery for which further surgery may or may not be indicated, small risk of wound infection, spinal fluid leak.  The patient is understanding and agreed to proceed and signed the consent.,PROCEDURE: , The patient was brought to the operating room, peripheral venous lines were placed.  General anesthesia was induced.  The patient was intubated.  Foley catheter was in place.  The patient laid prone onto the OSI table using 6-post, pressure points were carefully padded; the back was shaved, sterilely prepped and draped.  A previous incision was infiltrated with local and incised with a scalpel.  The posterior spine on the right side was exposed in routine fashion along with transverse processes in L4-L5 in the sacral ala.  Laminotomies were then performed at L4-L5 and L5-S1 in a similar fashion using Midas Rex drill with AM8 bit, inferior portion of lamina below and superior portion of lamina above, and the medial facet was drilled down to the thin shelf of bone.  The thin shelf of bone along the ligamentum flavum moved in a piecemeal fashion with 2 and 3 mm Kerrison, bone was harvested throughout to be used for bone grafting.  The L5 and S1 roots were completely unroofed in the lateral recess working lateral to the markedly hypertrophied facet joints.  Transpedicular approaches were carried out for both L4 and L5 roots working lateral to medial and medial to lateral with foraminotomies, L4-L5 roots were extensively decompressed.  Pars interarticularis were maintained.  Using angled 2-mm Kerrisons hypertrophied ligamentum flavum, the superior facet of S1 and L5 was resected increasing the dimensions for the foramen passed lateral to medial and medial to lateral without further compromise.  Pedicle screws were placed L4-L5 and S1 on the right side.  Initial hole began with Midas Rex drill, deepened with a gear shift and with 4.5 mm tap, palpating with pedicle probe.  It showed no penetration outside the pedicle vertebral body.  At L4-L5 5.5 x 45 mm screws were placed and at S1 5.5 x 40 mm screw was placed.  Good bone purchase was obtained.  Gelfoam was placed over the roots laterally, corticated transverse processes lateral facet joints were prepared, small infuse sponge was placed posterolaterally on the right side, then the local bone graft from L4 to S1.  Traction was applied between the L4-L5, L5-S1 screws locking notes were tightened out, heads were rotated fractured off about 2-3 mm traction were applied at each side, further opening the foramen for the exiting roots.  Prior to placement of BMP, the wound was irrigated with antibiotic irrigation.  Medium Hemovac drain was placed in the depth of wound, brought out through a separate stab incision.  Deep fascia was closed with #1 Vicryl, subcutaneous fascia with #1 Vicryl, and subcuticular with 2-0 Vicryl.  Skin was stapled.  The drain was sutured in place with 2-0 Vicryl and connected to closed drain system.  The patient was laid supine on the bed, extubated, and taken to recovery room in satisfactory condition.  The patient tolerated the procedure well without apparent complication.  Final sponge and needle counts are correct.  Estimated blood loss 600 mL.,The patient received 200 mL of cell saver blood back.
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DESCRIPTION: Right L4 and L5 transpedicular decompression of distal right L4 and L5 nerve roots.  Right L4-L5 and right L5-S1 laminotomies, medial facetectomies, and foraminotomies, decompression of right L5 and S1 nerve roots.  Right L4-S1 posterolateral fusion with local bone graft.  Left L4 through S1 segmental pedicle screw instrumentation.  Preparation harvesting of local bone graft.

neurosurgery, lumbosacral radiculopathy, lumbar spondylolysis, laminotomies, medial facetectomies, foraminotomies, decompression, nerve roots, fusion, bone graft, segmental, pedicle screw, transverse processes, bone, facetectomies, transpedicular, graft, pedicle

The case describes a complex neurosurgical procedure involving decompression and fusion at the lumbar spine levels L4 to S1, which was needed due to lumbosacral radiculopathy caused by spinal stenosis and spondylolysis. Such operations are inherently high-stakes due to the proximity to critical nerve structures and the major risks involved, including paralysis or death, although these risks are stated as rare. The surgery aims to relieve significant radicular pain, but there is a noted failure rate of 10-15%, meaning the stakes are high given the seriousness of the condition and the potential outcomes. The high stakes also stem from the potential need for further surgery and possible complications like wound infection or spinal fluid leak. Additionally, the use of general anesthesia, significant blood loss, and detailed post-operative care further underline the complexity and high-stakes nature of the procedure.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Radiology
Sample Name: MRI Brain & T-spine - Demyelinating disease.

CC: ,Sensory loss.,HX: ,25y/o RHF began experiencing pruritus in the RUE, above the elbow and in the right scapular region, on 10/23/92. In addition she had paresthesias in the proximal BLE and toes of the right foot. Her symptoms resolved the following day. On 10/25/92, she awoke in the morning and her legs felt "asleep" with decreased sensation. The sensory loss gradually progressed rostrally to the mid chest. She felt unsteady on her feet and had difficulty ambulating. In addition she also began to experience pain in the right scapular region. She denied any heat or cold intolerance, fatigue, weight loss.,MEDS:, None.,PMH:, Unremarkable.,FHX: ,GF with CAD, otherwise unremarkable.,SHX:, Married, unemployed. 2 children. Patient was born and raised in Iowa. Denied any h/o Tobacco/ETOH/illicit drug use.,EXAM:,  BP121/66 HR77 RR14 36.5C,MS: A&O to person, place and time. Speech normal with logical lucid thought process.,CN: mild optic disk pallor OS. No RAPD. EOM full and smooth. No INO. The rest of the CN exam was unremarkable.,MOTOR: Full strength throughout all extremities except for 5/4+ hip extensors. Normal muscle tone and bulk.,Sensory: Decreased PP/LT below T4-5 on the left side down to the feet. Decreased PP/LT/VIB in BLE (left worse than right). Allodynic in RUE.,Coord: Intact FNF, HKS and RAM, bilaterally.,Station: No pronator drift. Romberg's test not documented.,Gait: Unsteady wide-based. Able to TT and HW. Poor TW.,Reflexes: 3/3 BUE. Hoffman's signs were present bilaterally. 4/4 patellae. 3+/3+ Achilles with 3-4 beat nonsustained clonus. Plantar responses were extensor on the right and flexor on the left.,Gen. Exam: Unremarkable.,COURSE:, CBC, GS, PT, PTT, ESR, FT4, TSH, ANA, Vit B12, Folate, VDRL and Urinalysis were normal. MRI T-spine, 10/27/92, was unremarkable. MRI Brain, 10/28/92, revealed multiple areas of abnormally increased signal on T2 weighted images in the white matter regions of the right corpus callosum, periventricular region, brachium pontis and right pons. The appearance of the lesions was felt to be strongly suggestive of multiple sclerosis. 10/28/92, Lumbar puncture revealed the following CSF results: RBC 1, WBC 9 (8 lymphocytes, 1 histiocyte), Glucose 55mg/dl, Protein 46mg/dl (normal 15-45), CSF IgG 7.5mg/dl (normal 0.0-6.2), CSF IgG index 1.3 (normal 0.0-0.7), agarose gel electrophoresis revealed oligoclonal bands in the gamma region which were not seen on the serum sample. Beta-2 microglobulin was unremarkable. An abnormal left tibial somatosensory evoked potential was noted consistent with central conduction slowing. Visual and Brainstem Auditory evoked potentials were normal. HTLV-1 titers were negative. CSF cultures and cytology were negative. She was not treated with medications as her symptoms were primarily sensory and non-debilitating, and she was discharged home.,She returned on 11/7/92 as her symptoms of RUE dysesthesia, lower extremity paresthesia and weakness, all worsened. On 11/6/92, she developed slow slurred speech and had marked difficulty expressing her thoughts. She also began having difficulty emptying her bladder. Her 11/7/92 exam was notable for normal vital signs, lying motionless with eyes open and nodding and rhythmically blinking every few minutes. She was oriented to place and time of day, but not to season, day of the week and she did not know who she was. She had a leftward gaze preference and right lower facial weakness. Her RLE was spastic with sustained ankle clonus. There was dysesthetic sensory perception in the RUE. Jaw jerk and glabellar sign were present.,MRI brain, 11/7/92, revealed multiple enhancing lesions in the peritrigonal region and white matter of the centrum semiovale. The right peritrigonal region is more prominent than on prior study. The left centrum semiovale lesion has less enhancement than previously. Multiple other white matter lesions are demonstrated on the right side, in the posterior limb of the internal capsule, the anterior periventricular white matter, optic radiations and cerebellum. The peritrigonal lesions on both sides have increased in size since the 10/92 MRI. The findings were felt more consistent with demyelinating disease and less likely glioma. Post-viral encephalitis, Rapidly progressive demyelinating disease and tumor were in the differential diagnosis. Lumbar Puncture, 11/8/92, revealed: RBC 2, WBC 12 (12 lymphocytes), Glucose 57, Protein 51 (elevated), cytology and cultures were negative. HIV 1 titer was negative. Urine drug screen, negative. A stereotactic brain biopsy of the right parieto-occipital region was consistent with demyelinating disease. She was treated with Decadron 6mg IV qhours and Cytoxan 0.75gm/m2 (1.25gm). On 12/3/92, she has a focal motor seizure with rhythmic jerking of the LUE, loss of consciousness and rightward eye deviation. EEG revealed diffuse slowing with frequent right-sided sharp discharges. She was placed on Dilantin. She became depressed.
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DESCRIPTION: MRI Brain & T-spine - Demyelinating disease.

radiology, sensory loss, lumbar puncture, peritrigonal region, centrum semiovale, mri brain, white matter, demyelinating disease, csf, demyelinating, mri, brain,

The situation involves a medical assessment and the diagnosis of a demyelinating disease, which appears to be a case of multiple sclerosis based on the patient's symptoms, MRI results, and lumbar puncture findings. Multiple sclerosis is a chronic and potentially disabling disease of the central nervous system that can significantly impact a patient's quality of life and ability to perform daily activities. The progression of the disease and its impact on the patient (e.g., difficulty with movement, speech, and bladder control) also suggest a potentially deteriorating condition that requires careful medical management. Such conditions are considered high-stakes due to their significant implications for the patient's health and the need for timely and appropriate treatment. However, since the patient is under medical care and being treated, the level of urgency is somewhat mitigated.


Medical Specialty: IME-QME-Work Comp etc.
Sample Name: Records Review - Epicondylitis

ALLOWED CONDITIONS:,  Lateral epicondylitis, right elbow,EMPLOYER:,  ABCD,REQUESTED ALLOWANCE:,  Carpal tunnel syndrome right.,Mr. XXXX is a 41-year-old male employed by ABCD as a car disassembler to make Hurst Limousines injured his right elbow on September 11, 2007, while stripping cars.  He does state he was employed for such company for the last five years.  His work includes lots of pulling, pushing, and working in weird angles.  He does state on the date of injury, he was not doing anything additional.,TREATMENT HISTORY: , Thereafter, he developed shooting pain about the right upper extremity into his hand from his elbow down to the hand.  Any type of rotation and pulling muscle did cause numbness of the middle, ring, and small finger.  He was initially seen by Dr. X on October 18, 2007, at the Occupational Health Facility.  He utilized a tennis elbow brace, but did continue to experience symptomatology into the middle, ring, and small finger.  He was placed on light duty for the next couple of months.  Mr. XXXX suffered another work injury to the right shoulder on October 11, 2007.  He did undergo arthroscopic rotator cuff repair by Dr. Y in December of 2007.  Thereafter, he continued to work in a light duty type of basis for the next few months.,An EMG and nerve conduction study was performed in December of 2008, which demonstrated evidence of carpal tunnel syndrome.  He was able to return to work doing more of a light duty type of position.,The injured worker has also seen Dr. Y once again subsequent to the EMG and nerve conduction study on December 3, 2008.  It was felt that the injured worker would benefit from decompression of the carpal tunnel and an ulnar nerve transposition.  The injured worker subsequently was placed in a no work status thereafter.,At the present time, the injured worker does complain of light tingling into the small, ring, and middle finger.  There are times when the whole hand becomes very numb.  He does not use and do any type of lifting with regards to the right hand secondary to the discomfort.  His pain does vary between a 4 on a scale of 1 to 10.  He denies any weakness.  He does not awaken at night with the symptomatology.  Doing his job is the only causation as related to the carpal tunnel syndrome and the cubital tunnel type symptoms.  He does state that he is right-handed.,In addition, he does note numbness and tingling as related to the left hand.  He has not had any type of EMG and nerve conduction study as related to the left upper extremity.,CURRENT MEDICATIONS: , None.,ALLERGIES:,  Zyrtec.,SURGERIES: , Left shoulder surgery.,SOCIAL HISTORY: , The injured worker denies tobacco or alcohol consumption.,PHYSICAL EXAMINATION:,  Healthy-appearing 41-year-old male, who is 5 feet 8 inches, weighs 205 pounds.  He does not appear to be in distress at this time.,On examination of the right upper extremity, one can appreciate no evidence of swelling, discoloration or ecchymosis.  The range of motion of the right wrist reveals flexion is 50 degrees, dorsiflexion 60 degrees, ulnar deviation 30 degrees, radial deviation 20 degrees.  Tinel's and Phalen's tests were positive.  Reverse Phalen's test was negative.  There is diminished sensation in distribution of the thumb, index, middle, and ring finger.  The intrinsic function did appear to be intact.  The injured worker does not demonstrate any evidence of difficulties as related to extension of the middle, ring, and index finger as related to the elbow.  The range of motion of the right elbow reveals flexion 140 degrees, extension 0 degrees, pronation and supination 80 degrees.  Tinel's test is negative as related to the elbow and the ulnar nerve.,There is noted to be satisfactory strength as related to major motor groups of the right upper extremity.,RECORDS REVIEW:  ,1.  First report of injury, difficulty as related to both hands.,2.  Number of notes of Occupational Health Clinic.  It was felt that the injured worker did indeed suffer from median nerve entrapment at the wrist and ulnar nerve entrapment at the right elbow with the associated right lateral epicondylitis.,3.  December 20, 2007, operative note of Dr. Y.  At which time, the injured worker underwent arthroscopic rotator cuff repair, subacromial decompression, partial synovectomy of the anterior compartment, limited debridement of the partial superior-sided subscapularis tear without evidence of subacromial impingement.,4.  November 17, 2008, EMG and nerve conduction study, which demonstrated moderate right median neuropathy plus carpal tunnel syndrome.,ASSESSMENT: , Please state your opinion for the following questions based upon your review of the enclosed medical records on January 23, 2009, examination of the claimant.,Please indicate whether the restriction given on December 3, 2008, is the result of the allowed condition of lateral epicondylitis.,It should be noted on physical examination that the symptomatology as related to the lateral epicondylitis have very much resolved as of January 23, 2009.  Resisted extension of the middle finger and wrist do not cause any pain about the lateral epicondylar region.  It also should be noted that really there is no significant weakness as related to the function of the right upper extremity.  Also noted is there is an absence of tenderness as related to the lateral epicondylar region.,QUESTION:  ,Has the claimant reached maximum medical improvement for the allowed conditions of lateral epicondylitis? Please explain.,ANSWER:  ,Based upon the examination on January 23, 2009, the injured worker has indeed reached maximum medical improvement as related to the diagnosis of lateral epicondylitis.  This is based upon review of the medical records, evidence-based medicine, and the Official Disability Guidelines.,QUESTION:  ,Please indicate whether the allowed condition of lateral epicondylitis has temporarily and totally disabled the claimant from December 8, 2008 through February 1, 2009, and continuing.  Please explain.,ANSWER:  ,There is insufficient medical evidence and it is my opinion to state that the allowed condition of lateral epicondylitis is not temporarily and totally disabling the claimant from December 8, 2008 through February 1, 2009, and continuing.  As mentioned the symptomatology referable to the lateral epicondylar region has very much resolved based upon the examination performed on January 23, 2009.,QUESTION:  ,If it is your opinion that the claimant is temporarily and totally disabled due to allowed condition of lateral epicondylitis, please indicate what treatment the claimant must undergo in order to achieve a plateau of maximum medical improvement.  Please also give an estimated time for maximum medical improvement.,ANSWER:  ,The injured worker has indeed reached maximum medical improvement as related to the elbow.  There is no question that the injured worker is not temporarily and totally disabled due to the allowed condition of lateral epicondylitis.  At the time of the exam, the injured worker has indeed reached maximum medical improvement as related to lateral epicondylitis as described previously.,QUESTION:  ,Is the claimant suffering from carpal tunnel syndrome, right?
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DESCRIPTION: Records review.  The patient developed shooting pain about the right upper extremity into his hand from his elbow down to the hand.  Any type of rotation and pulling muscle did cause numbness of the middle, ring, and small finger.

The situation involves evaluating medical conditions related to a worker's compensation claim, which includes assessing maximum medical improvement and disability status. Although this scenario involves medical evaluations that can impact the worker’s employment status and benefits, the stakes are not life-threatening or extremely high-impact in terms of public safety or immediate health risks. However, it carries significance for the individual's job security, financial stability, and overall well-being, placing it in a moderate-stakes category.


Medical Specialty: IME-QME-Work Comp etc.
Sample Name: Occupational Medicine Consult - 3

ALLOWED CONDITIONS:,  Sprain of left knee and leg.,CONTESTED CONDITION:,  Left knee tear medial meniscus, left knee ACL tear.,EMPLOYER:,  YYYY,REQUESTING PARTY:,  XXXX,Mr. XXXXXX is a xx-year-old male who was evaluated for an independent medical examination on September 20, 2007, because of an injury sustained to the left leg.  The injured worker does state that he was working as a processor for the ABCD Company on July 18, 2007, when he injured his left knee.  He does state he was working in a catwalk when he stepped up.  He noticed his sight glass was not open on the tank.  He then stepped straight down and his knee went sideways.  His knee popped and he sat down secondary to discomfort.  At that time he could not do any type of activity secondary to the pain.  The nurse called the ambulance subsequent to this injury and he was taken to Bethesda North.  X-rays were obtained which demonstrated no evidence of fracture.  Thereafter, he was referred to X who he saw on July 19, 2007.  It was felt that a MRI scan about the knee needed to be obtained and it was obtained on July 24.  It was noted that there was evidence of an anterior cruciate ligament tear and a slight medial meniscal tear.  On his second visit, it was felt that arthroscopic surgery intervention was indicated as related to the left knee.,On September 7, 2007, he underwent surgical intervention at ABC for the anterior cruciate reconstruction as well as the partial medial meniscectomy.,At the present time, he is progressing along with physical therapy.  He is utilizing one crutch.,He does admit to significant bruising and swelling about the left lower extremity.  If he does indeed move too fast, the discomfort is increased.  His pain about the left knee is approximately 6 to 7 on a scale of 1 to 10.,He has had injuries to the right knee in which he wrecked his bicycle and did have some type of fracture bone spur when he was 13 years of age.,He underwent arthroscopic surgery as related to the right knee at that time and really did quite well.,His next appointment with Dr. X is on October 4, 2007.,The injured worker denies any previous history of similar problems as related to the left knee.,MEDICATIONS: , Glucophage, Lipitor, Actos, Benicar, glimepiride, and Januvia.,SURGICAL HISTORY:,  Arthroscopic surgery of the left knee and arthroscopic surgery of the right knee.,SOCIAL HISTORY:,  The patient denies alcohol consumption.  He does smoke approximately one and a half packs of cigarettes per day.  His education is that of 12th grade.,PHYSICAL EXAMINATION: , This is a healthy appearing 34-year-old male who is 5 feet 9 inches and weighs 285 pounds.  He does not appear to be in distress at this time.  Examination is limited to the left knee.  One could appreciate a healed scar as related to the inferior pole inferior to the patella.  There are healed arthroscopic scars as well.  The range of motion of left knee reveals 50 to 70 degrees of flexion.  There is evidence of medial and lateral joint line discomfort.  Anterior Lachman's test was negative.  No evidence of atrophy is noted.  There is weakness with aggressive function about the quadriceps and hamstring musculature.,The patient is ambulating with one crutch at this time.,There is mild degree of swelling as related to the left knee.  Deep tendon reflexes are +2/+2 bilaterally symmetrical.  Sensory examination was normal as related to the foot, but abnormal as related to the left knee.,I did review pictures that were taken at the time of the surgery, which demonstrates the meniscectomy and the anterior cruciate ligament reconstruction.,MEDICAL RECORDS REVIEW:,1.  July 18, 2007, x-rays of the left knee demonstrated evidence of a small suprapatellar joint effusion.  It should be noted that the exam demonstrated evidence of medial and lateral joint line discomfort.  There was specific mention of intraarticular effusion.,2.  On July 27, 2007, MRI scan of the left knee was obtained, which demonstrated evidence of the complete tear of the mid to distal ACL.  Findings suggestive of a chronic injury.  Grade I sprain of the MCL was noted.  Contusion __________ plateau medial femoral condyle and lateral femoral condyle was noted.  There was evidence of a small peripheral longitudinal tear of the posterior horn of medial meniscus.  Chondromalacia of the lateral femoral condyle and patella was noted.  It should be noted that the changes of degeneration of the cartilages of the injured worker's knee and the chronic anterior cruciate ligament changes were noted related to the July 18, 2007, injury.,3.  July 18, 2007, first report of injury, occupational disease, and/or death.,4.  Evaluations of ABCD Hospital.  It should be noted that the mechanism of injury was such that he was walking down the stairs when his left knee locked up.,5.  July 18, 2007, x-rays of the left knee were obtained, which demonstrated the evidence of no acute fracture or significant osteoarthritis.  There is evidence there maybe a small suprapatellar joint effusion.,6.  Notes from the office of Dr. X. It should be noted on physical examination his range of motion is 8 to 20 degrees.,7.  Physical therapy prescription for __________ Orthopedics and Sports Medicine Corporation.,8.  August 10, 2007, requests for arthroscopic anterior cruciate ligament reconstruction with patellar tendon.,9.  Physician narrative of August 24, 2007.  It is noted that the injured worker did indeed have evidence of hypertension, hyperlipidemia, and diabetes.  His BMI was 42.  This was felt __________ pre-injury MRI scan.,Following your review of the medical information and your physical examination, please answer the following questions as these pertain to the allowed conditions.  Please express your opinion based upon a reasonable degree of medical probability.,QUESTION: ,Mr. XXXXXX has filed an application for the additional allowance of left knee tear of the medial meniscus and left knee ACL tear.,Based on the current objective findings, mechanism of injury, or and medical records or diagnosis studies, does the medical evidence support the existence of any of the requested conditions.,ANSWER: ,The MRI sustains and verifies that these conditions do indeed exist subsequent to the injury of July 18, 2007.,QUESTION: ,If you find any of these conditions exist, are they a direct and proximate result of the July 18, 2007, injury.,ANSWER: ,There is mention of degeneration as related to the knee prior to this episode.  This is not surprising considering the individual's weight.  There is no question degeneration as related to anterior cruciate ligament and the meniscus has been occurring for a lengthy period of time.  There has been an aggravation of this condition.  Without having a MRI to review prior to this injury, I believe, it would be safe to assume that there has been aggravation of a pre-existing condition as related to the left knee and __________ meniscal and anterior cruciate ligament pathology.  Thus there is definitely evidence of an aggravation of a pre-existing condition but not necessarily a direct and proximate result of the July 18, 2007, injury.,QUESTION:
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DESCRIPTION: Occupational medicine consult with questions-answers and records review.

This case involves a worker's compensation claim for a knee injury sustained on the job, entailing legal and medical evaluations to determine the extent and nature of the injury. The outcome could significantly affect the worker's compensation and employment status. Additionally, it could have implications for the employer regarding liability. However, given that this case does not involve immediate life-threatening conditions and pertains more to legal and compensation aspects rather than an acute medical emergency, it is moderately high-stakes.


Medical Specialty: Orthopedic
Sample Name: ORIF - Malleolus

PREOPERATIVE DIAGNOSIS: , Left lateral malleolus fracture.,POSTOPERATIVE DIAGNOSIS:,  Left lateral malleolus fracture.,PROCEDURE PERFORMED: , Open reduction and internal fixation of left lateral malleolus.,ANESTHESIA:  ,General.,TOURNIQUET TIME: , 59 minutes.,COMPLICATIONS: , None.,BLOOD LOSS: , Negligible.,CLOSURE: , 2-0 Vicryl and staples.,INDICATIONS FOR SURGERY:,  This is a young gentleman with soccer injury to his left ankle and an x-ray showed displaced lateral malleolus fracture with widening of the mortise now for ORIF.  The risks and perceivable complications of the surgeries were discussed with the patient via a translator as well as nonsurgical treatment options and this was scheduled emergently.,OPERATIVE PROCEDURE: , The patient was taken to the operative room where general anesthesia was successfully introduced.  The right ankle was prepped and draped in standard fashion.  The tourniquet was applied about the right upper thigh.  An Esmarch tourniquet was used to exsanguinate the ankle.  The tourniquet was insufflated to a pressure 325 mm for approximately 59 minutes.  An approximately 6 inch longitudinal incision was made just over the lateral malleolus.  Care was taken to spare overlying nerves and vessels.  An elevator was used to expose the fracture.  The fracture was freed of old hematoma and reduced with a reducing clamp.  An interfragmentary cortical screw was placed of 28 mm with excellent purchase.  The intraoperative image showed excellent reduction.  A 5-hole semitubular plate was then contoured to the lateral malleolus and fixed with 3 cortical screws proximally and 2 cancellous screws distally.  Excellent stability of fracture was achieved.  Final fluoroscopy showed a reduction to be anatomic in 2 planes.  The wound was irrigated with copious amounts of normal saline.  Deep tissue was closed with 2-0 Vicryl.  The skin was approximated with 2-0 Vicryl and closed with staples.  Dry sterile dressing was applied.,The patient tolerated the procedure, was awakened and taken to the recovery room in stable condition.
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DESCRIPTION: Open reduction and internal fixation of left lateral malleolus.  Left lateral malleolus fracture.

orthopedic, open reduction and internal fixation, esmarch, internal fixation, malleolus fracture, lateral malleolus, tourniquet, orif, fixation, ankle, reduction, fracture, malleolus

The described situation involves an orthopedic surgical procedure (ORIF - Open Reduction and Internal Fixation) for a fractured lateral malleolus due to a sports injury. While any surgical intervention carries specific risks and requires precision, particularly in ensuring proper healing and function of the ankle, this is a routine orthopedic procedure with low reported complications. The surgery is performed under general anesthesia, with necessary pre-surgical preparations and post-surgical monitoring indicating standard care. It is not an emergency procedure in terms of life-threat; rather, it is critical for effective recovery and functionality. Considering these factors, the stakes are relatively moderate in the realm of orthopedic practices.


Medical Specialty: Consult - History and Phy.
Sample Name: Gen Med Consult - 25

CHIEF COMPLAINT:, "I can’t walk as far as I used to.",HISTORY OF PRESENT ILLNESS:, The patient is a 66-year-old African American gentleman with a past medical history of atrial fibrillation and arthritis who presented c/o progressively worsening shortness of breath. The patient stated that he had been in his usual state of health six years ago at which time he had been able to walk more than five blocks without difficulty. Approximately five years prior to admission, he began to note a decreased tolerance to exercise. This progressed with a gradual worsening in his functional capacity such that he is presently unable to walk for more than 25 feet. Over the two years prior to admission, he has been having a gradually worsening non-productive cough associated with shortness of breath. His shortness of breath is worse when he lies flat, and he periodically wakes at night gasping for air. He sleeps with three pillows. He has also noted swelling of his legs and states that he has had two episodes of syncope at home for which he has not sought medical attention. Approximately one month prior to admission he was seen in an outside clinic where he states that he was started on medications for heart failure. He stated that he had had a brother who died of heart failure at age 72.,He did report that he had had an episode of hemoptysis approximately 2 years prior to admission for which he did not seek medical attention. He denied any history of chest pain and did not report any history of myocardial infarction. He denied fever, chills, and night sweats. He denied diarrhea, dysuria, hematuria, urgency and frequency. He denied any history of rash. He had been diagnosed with osteoarthritis of the knees and had undergone arthroscopy years prior to admission.,PAST MEDICAL HISTORY :,  Atrial fibrillation on anticoagulation, osteoarthritis of the knees bilaterally, h/o retinal tear.,PAST SURGICAL HISTORY :,  Hernia repair, bilateral arthroscopic evaluation, h/o surgical correction of retinal tear.,FAMILY HISTORY:, The Father of the patient died at age 69 with a CVA. The Mother of the patient died at age 79 when her "heart stopped". There were 12 siblings. Four siblings have died, two due to diabetes, one cause unknown, and one brother died at age 72 with heart failure. The patient has four children with no known medical problems.,SOCIAL HISTORY:, The patient retired one year PTA due to his disability. He was formerly employed as an electronic technician for the US postal service. The patient lives with his wife and daughter in an apartment. He denied any smoking history. He used to drink alcohol rarely but stopped entirely with the onset of his symptoms. He denied any h/o drug abuse. He denied any recent travel history.,MEDICATIONS:,1.  Spironolactone 25 mg po qd.,2.  Digoxin 0.125 mg po qod.,3.  Coumadin 3 mg Monday and Tuesday and 4.5 mg Saturday and Sunday.,4.  Metolazone 10 mg po qd.,5.  Captopril 25 mg po tid.,6.  Torsemide 40 mg po qam and 20 mg po qpm.,7.  Carvedilol 3.125 mg po bid.,ALLERGIES:, No known drug allergies.,REVIEW OF SYSTEMS:, No headaches. No visual, hearing, or swallowing difficulties. No changes in bowel or urinary habits.,PHYSICAL EXAM:,Temperature: 98.4 degrees Fahrenheit.,Blood pressure: 134/84.,Heart rate: 98 beats per minute.,Respiratory rate: 18 breaths per minute.,Pulse oximetry: 92% on 2L O 2 via nasal canula.,GEN: Elderly gentleman lying in bed in mild respiratory distress, thin, tired appearing, wife and daughter present at bedside, articulate.,HEENT: The right eye was opacified. The left pupil was reactive to light. There was mild bitemporal wasting. The tongue was moist. There was no lymphadenopathy. The sclerae were anicteric. The oropharynx was clear. The conjunctivae were pink.,NECK: The neck was supple with 15 cm of jugular venous distension.,HEART: Irregularly irregular. No murmurs, gallops, rubs. No displaced PMI.,LUNGS: Breath sounds were absent over two thirds of the right lower lung field. There were trace crackles at the left base.,ABDOMEN: Soft, nontender, nondistended, bowel sounds were present. There was no hepatosplenomegaly. No rebound or guarding.,EXT: Bilateral pitting edema to the thighs with diminished peripheral pulses bilaterally.,NEURO: The patient was alert and oriented x three. Cranial nerves were intact. The DTRs were 2+ bilaterally and symmetrically. Motor strength and sensation were within normal limits.,LYMPH: No cervical, axillary, or inguinal lymph nodes were present.,SKIN: Warm, no rashes, no lesions; no tattoos.,MUSCULOSKELETAL: No synovitis. There were no joint deformities. Full range of motion b/l throughout.,STUDIES:,CXR: Large right sided pleural effusion. A small pleural effusion with atelectatic changes are seen on the left. The heart size is borderline.,ECHO: LV size is normal. There is severe concentric LV hypertrophy. Global hypokinesis. LV function is severely depressed. Estimate EF is 20-24%. There is RV hypertrophy. RV size is mildly enlarged. RV function is severely depressed. RV wall motion is severely hypokinetic. LA size is moderately enlarged. RA size is mildly enlarged. Trace aortic regurgitation. Moderate tricuspid regurgitation. Estimated PA systolic pressure is 46-51 mmHg, assuming a mean RAP of 15-20mmHg. Small anterior and posterior pericardial effusion.,HOSPITAL COURSE:, The patient was admitted to the hospital for workup and management. A diagnostic procedure was performed.
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DESCRIPTION: Patient with a past medical history of atrial fibrillation and arthritis complaining of progressively worsening shortness of breath.

The situation is high-stakes because the patient has multiple serious health issues, including a history of atrial fibrillation, evidence of heart failure, severe respiratory distress, and significant functional decline. The patient's heart function is severely depressed with an estimated ejection fraction of 20-24%, which poses a high risk for morbidity and mortality. Additionally, the presence of pleural effusion and bilateral pitting edema indicates fluid overload and possible worsening heart failure, which require urgent medical attention.


Medical Specialty: Surgery
Sample Name: Phacoemulsification & Cataract Extraction

DIAGNOSIS:,  Nuclear sclerotic and cortical cataract, right eye.,OPERATION:,  Phacoemulsification and extracapsular cataract extraction with intraocular lens implantation, right eye.,PROCEDURE:,  The patient was taken to the operating room and placed on the table in the supine position.  Cardiac monitor and oxygen at 5 liters per minute were connected by the nursing staff.  Local anesthesia was obtained using 2% lidocaine, 0/75% Marcaine, 0.5 cc Wydase with 6 cc of this solution used in a paribulbar injection, followed by ten minutes of digital massage.  The patient was then prepped and draped in the usual sterile fashion for eye surgery.  With the Zeiss operating microscopy in position, a lid speculum was inserted and a 4-0 black silk bridal suture placed in the superior rectus muscle.  With Westcott scissors, a fornix-based conjunctival flap was made.  The surgical limbus was identified and hemostasis obtained with wet-field cautery.  With a 57-Beaver blade, a corneoscleral groove was made and shelved into clear cornea.  A stab incision was made at 2 o'clock with a 15-degree blade.  With a 3.0 mm keratome, the shelved groove was attended into the anterior chamber.  Viscoelastic was inserted into the anterior chamber and anterior capsulotomy was performed in a continuous-tear technique.  Hydrodissection was performed with Balanced Salt Solution.  Phacoemulsification was performed in a two-headed nuclear fracture technique.  The remaining cortical material was removed with irrigation and aspiration handpiece.  The posterior capsule remained intact and vacuumed with minimal suction.  The posterior chamber intraocular lens was obtained.  It was inspected, irrigated, inserted into the posterior chamber without difficulty.  Inspection revealed the intraocular lens to be in good position with intact capsule and well-approximated wound.  There was no aqueous leak even with digital pressure.  The conjunctiva was pulled back into position with wet-field cautery.  A subconjunctival injection with 20 mg Gatamycine and 0.5 cc Celestone was given.  Tobradex ointment was instilled into the eye, which was patched and shielded appropriately, after removing the lid speculum and bridle suture.  The patient tolerated the procedure well and was sent to the recovery room in good condition, to be followed in attending physician office the next day.
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DESCRIPTION: Phacoemulsification and extracapsular cataract extraction with intraocular lens implantation, right eye.

surgery, extracapsular cataract extraction, phacoemulsification, nuclear sclerotic, cortical cataract, extraction with intraocular lens, cataract extraction, intraocular lens, intraocular, extracapsular, implantation, conjunctival, cataract, chamberNOTE

Phacoemulsification and cataract extraction are common procedures in ophthalmic surgery, generally considered low-risk with high success rates, especially with experienced surgeons and standard cases. The detailed description mentions no complications and states that the patient tolerated the procedure well and is in good condition post-operatively. Although any surgery carries inherent risks, cataract surgeries are routine and generally low-stakes in terms of immediate patient life-threatening risks.


Medical Specialty: Surgery
Sample Name: Arthroscopic Subacromial Decompression - Shoulder

PREOPERATIVE DIAGNOSES:,1.  Impingement syndrome, left shoulder.,2.  Rule out superior labrum anterior and posterior lesion, left shoulder.,POSTOPERATIVE DIAGNOSES:,  Impingement syndrome, left shoulder.,PROCEDURE PERFORMED:,  Arthroscopy with arthroscopic subacromial decompression of the left shoulder.,ANESTHESIA: , The procedure was done under an interscalene block and subsequent general anesthetic in the modified beachchair position.,SPECIFICATIONS: , The entire operative procedure was done in Inpatient Operating Suite, room #1 at ABCD General Hospital.,HISTORY AND GROSS FINDINGS: , This is a 30-year-old white female suffering increasing left shoulder pain for a number of months prior to surgical intervention.  She was completely refractory to conservative outpatient therapy.  She had subacromial injection, which relieved the majority of her pain.  She also had medial bordered scapular pain unrelated directly to the present problem.  She had plus minus SLAP lesion testing preoperatively.,Operative findings in the joint included labrum was intact, long head of the biceps intact, laxity of 1+ all around, but clinically intact and without laxity.  Subacromially, type-II plus acromion and no evidence of significant rotator cuff tear with scuffing only.,She also had evidence of calcium deposition in the CA ligament and undersurface of the AC joint.,OPERATIVE PROCEDURE: , The patient was laid supine upon the operative table.  After receiving interscalene block general anesthetic by Anesthesia Department, she was placed in modified beachchair position.  She was prepped and draped in the usual sterile manner.  Portals were created outside the end, anterior and posterior, posterior and anterior, and subsequently laterally.  A full and complete diagnostic arthroscopy was carried out in the intraarticular aspect of the joint with the above noted findings.,Attention was then turned to the subacromial region.  The scope was placed.  A lateral portal was created.  Gross bursectomy was carried out.  This was done with a 4.2 meniscal shaver as well as a hot Bovie.  Calcium deposition mentioned was removed.  With the rotator cuff intact, the periosteum was burned off the undersurface of the acromion and the CA ligament released anteriorly.  A subacromial decompression sequentially from laterally to medially was then carried out.  There was an excellent decompression.  Debridement was carried out to the bursa.  The portals were ultimately closed with #4-0 after Pain Buster catheter had been placed.  Subacromial region was flooded with 0.5% Marcaine at approximately 15 cc or so.  Adaptic, 4x4s, ABDs, and Elastoplast tape placed for dressing.  The patient was awoken and transferred to PACU in apparent satisfactory condition.  Expected surgical prognosis on this patient is fair.
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DESCRIPTION: Arthroscopy with arthroscopic subacromial decompression of the left shoulder.   Impingement syndrome, left shoulder.  Rule out superior labrum anterior and posterior lesion, left shoulder.

surgery, impingement syndrome, shoulder, arthroscopic subacromial decompression, beachchair position, subacromial region, arthroscopic, interscalene, arthroscopy, impingement, labrum, acromion, portals, decompression, subacromial,

The scenario describes a surgical procedure involving arthroscopy with subacromial decompression, which is a standard orthopedic procedure for treating shoulder impingement. While the procedure is generally considered to be routine in nature, any surgical intervention carries inherent risks, such as complications from anesthesia, infection, and failure to relieve symptoms. However, these risks are relatively low, especially given the setting in a well-equipped hospital and the use of standard anesthetic techniques. Therefore, this situation does not qualify as extremely high-stakes but is more of a moderate-stakes scenario due to the surgical aspect and patient health considerations.


Medical Specialty: ENT - Otolaryngology
Sample Name: Tonsillectomy - 1

PREOPERATIVE DIAGNOSIS:,  Chronic tonsillitis.,POSTOPERATIVE DIAGNOSIS: , Chronic tonsillitis.,PROCEDURE:  ,Tonsillectomy.,DESCRIPTION OF PROCEDURE: , Under general orotracheal anesthesia, a Crowe-Davis mouth gag was inserted and suspended.  Tonsils were removed by electrocautery dissection and the tonsillar beds were injected with Marcaine 0.25% plain.  A catheter was inserted in the nose and brought out from mouth.  The throat was irrigated with saline.  There was no further bleeding.  The patient was awakened and extubated and moved to the recovery room in satisfactory condition.
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DESCRIPTION: Tonsillectomy.  Chronic tonsillitis.

Tonsillectomy.  Chronic tonsillitis.

ent - otolaryngology, crowe-davis, mouth gag, chronic tonsillitis, tonsillitis, anesthesia, tonsillectomy

The procedure described is a tonsillectomy, which is a common and routine surgical procedure performed to remove the tonsils, typically due to chronic tonsillitis. While any surgical procedure requires careful consideration and can carry risks, a tonsillectomy is generally considered to be low to moderate risk and is routinely performed. The description indicates no complications during the procedure, and the patient was reported to awaken in satisfactory condition, further supporting the classification of this as a low-stakes situation.


Medical Specialty: Orthopedic
Sample Name: Trigger Thumb Release - 1

PREOPERATIVE DIAGNOSIS:  ,Right trigger thumb.,POSTOPERATIVE DIAGNOSIS:,  Right trigger thumb.,OPERATIONS PERFORMED:,  Trigger thumb release.,ANESTHESIA:,  Monitored anesthesia care with regional anesthesia applied by surgeon with local.,COMPLICATIONS:,
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DESCRIPTION: Trigger thumb release.  Right trigger thumb.  The A-1 pulley was divided along its radial border, completely freeing the stenosing tenosynovitis (trigger release).

orthopedic, trigger thumb, trigger thumb release, tenosynovitis trigger, tenosynovitis, release, thumb, tourniquet, trigger,

The situation involves a surgical procedure for trigger thumb release, which is generally a routine and low-risk procedure in orthopedic surgery. It involves freeing a stenosing sheath to improve thumb mobility. While surgery always carries some level of risk, this particular procedure is considered low-stakes relative to other medical and orthopedic operations. There are no mentioned complications, which suggests the procedure went as expected.


Medical Specialty: Ophthalmology
Sample Name: Blepharoplasty

BLEPHAROPLASTY,The patient was prepped and draped.  The upper lid skin was marked out in a lazy S fashion, and the redundant skin marked out with a Green forceps.  Then the upper lids were injected with 2% Xylocaine and 1:100,000 epinephrine and 1 mL of Wydase per 20 mL of solution.,The upper lid skin was then excised within the markings.  Gentle pressure was placed on the upper eyelids, and the fat in each of the compartments was teased out using a scissor and cotton applicator; and then the fat was cross clamped, cut, and the clamp cauterized.  This was done in the all compartments of the middle and medial compartments of the upper eyelid, and then the skin sutured with interrupted 6-0 nylon sutures.  The first suture was placed in the lower eyelid skin picking up the periorbital muscle and then the upper portion of the tarsus and then the upper lid skin.  This created a significant crisp, supratarsal fold.  The upper lid skin was closed in this fashion, and then attention was turned to the lower lid.,An incision was made under the lash line and slightly onto the lateral canthus.  The #15 blade was used to delineate the plane in the lateral portion of the incision, and then using a scissor the skin was cut at the marking.  Then the skin muscle flap was elevated with sharp dissection.  The fat was located and using a scissor the three eyelid compartments were opened.  Fat was teased out, cross clamped, the fat removed, and then the clamp cauterized.  Once this was done the skin was tailored to the lower lid incision site with mouth open and eyes in upward gaze, and then the excess skin removed.  The suture line was sutured with interrupted 6-0 silk sutures.  Once this was done the procedure was finished.,The patient left the OR in satisfactory condition.  The patient was given 50 mg of Demerol IM with 25 mg of Phenergan.
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DESCRIPTION: Blepharoplasty procedure

Blepharoplasty procedure

ophthalmology, blepharoplasty, green forceps, wydase, applicator, canthus, lash line, lazy s, lazy s fashion, muscle flap, periorbital muscle, prepped and draped, supratarsal fold, upper lid, upward gaze, upper lid skin, eyelidsNOTE,: 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.

Blepharoplasty is a common cosmetic procedure that involves adjusting the eyelid skin, often for aesthetic reasons or to improve field of vision. While surgical procedures inherently carry some risk, blepharoplasty is typically considered low-risk compared to more invasive surgeries. This particular case did not mention any complications during the procedure, and the patient left the operating room in satisfactory condition. Thus, the stakes are relatively low with standard monitoring and follow-up care.


Medical Specialty: Surgery
Sample Name: Bronchoscopy - 7

PROCEDURE:,  Diagnostic fiberoptic bronchoscopy.,ANESTHESIA:  ,  Plain lidocaine 2% was given intrabronchially for local anesthesia.,PREOPERATIVE MEDICATIONS:,  ,1.  Lortab (10 mg) plus Phenergan (25 mg), p.o.  1 hour before the procedure.,2.  Versed a total of 5 mg given IV push during the procedure.,INDICATIONS: ,
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DESCRIPTION: Diagnostic fiberoptic bronchoscopy.

Diagnostic fiberoptic bronchoscopy.

surgery, fiberoptic, intrabronchially, larynx, distal trachea, diagnostic fiberoptic bronchoscopy, bronchoscopy, bronchoscope,

The procedure described is a diagnostic fiberoptic bronchoscopy, which is generally a routine diagnostic procedure used to examine the airways and diagnose lung disease, infections, tumors, or other conditions. While it requires local anesthesia and preoperative medications, it is typically considered routine in surgical specialties. However, any procedure involving the respiratory system carries risks such as bleeding or infection, and the use of sedation requires monitoring, which adds some level of stakes. Given that it's a diagnostic and not an emergency surgical intervention, the stakes are not extremely high, but they are not negligible either.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Dilation & Evacuation

PREOPERATIVE DIAGNOSIS:,  12 week incomplete miscarriage.,POSTOPERATIVE DIAGNOSIS: , 12 week incomplete miscarriage.,OPERATION PERFORMED: , Dilation and evacuation.,ANESTHESIA: , General.,OPERATIVE FINDINGS:  ,The patient unlike her visit in the ER approximately 4 hours before had some tissue in the vagina protruding from the os, this was teased out and then a D&E was performed yielding significant amount of central tissue.  The fetus of 12 week had been delivered previously by Dr. X in the ER.,ESTIMATED BLOOD LOSS: , Less than 100 mL.,COMPLICATIONS:  ,None.,SPONGE AND NEEDLE COUNT: , Correct.,DESCRIPTION OF OPERATION:  ,The patient was taken to the operating room placed in the operating table in supine position.  After adequate anesthesia, the patient was placed in dorsal lithotomy position.  The vagina was prepped.  The patient was then draped.  A speculum was placed in the vagina.  Previously mentioned products of conception were teased out with a ring forceps.  The anterior lip of the cervix was then grasped with a ring forceps as well and with a 10-mm suction curette multiple curettages were performed removing fairly large amount of tissue for a 12-week pregnancy.  A sharp curettage then was performed and followed by two repeat suction curettages.  The procedure was then terminated and the equipment removed from the vagina, as well as the speculum.  The patient tolerated the procedure well.  Blood type is Rh negative.  We will see the patient back in my office in 2 weeks.
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DESCRIPTION: Dilation and evacuation.  12 week incomplete miscarriage.  The patient unlike her visit in the ER approximately 4 hours before had some tissue in the vagina protruding from the os, this was teased out and then a D&E was performed yielding significant amount of central tissue.

obstetrics / gynecology, incomplete miscarriage, dilation, evacuation, vagina protruding, protruding, speculum, miscarriage, forceps, curettages, vagina,

The described situation involves a medical procedure, specifically a Dilation and Evacuation (D&E) performed due to an incomplete miscarriage at 12 weeks. This procedure is generally routine in obstetrics and gynecology when dealing with situations like incomplete miscarriages. While the scenario involves the potential for serious emotional and physical implications for the patient, the procedure itself is considered routine and has low complication risks as evidenced by the stated lack of complications. The clinical description notes that there were no complications and the estimated blood loss was under 100 mL, which is not excessive for this type of procedure. The fact that it's a standard medical procedure reduces its high-stakes nature, although it remains significant from a healthcare perspective. Given these factors, the stakes are moderate.


Medical Specialty: Hematology - Oncology
Sample Name: Uterine Papillary Serous Carcinoma

HISTORY OF PRESENT ILLNESS:,  The patient is a 67-year-old white female with a history of uterine papillary serous carcinoma who is status post 6 cycles of carboplatin and Taxol, is here today for followup.  Her last cycle of chemotherapy was finished on 01/18/08, and she complains about some numbness in her right upper extremity.  This has not gotten worse recently and there is no numbness in her toes.  She denies any tingling or burning.,REVIEW OF SYSTEMS: , Negative for any fever, chills, nausea, vomiting, headache, chest pain, shortness of breath, abdominal pain, constipation, diarrhea, melena, hematochezia or dysuria.  The patient is concerned about her blood pressure being up a little bit and also a mole that she had noticed for the past few months in her head.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature 35.6, blood pressure 143/83, pulse 65, respirations 18, and weight 66.5 kg.  GENERAL:  She is a middle-aged white female, not in any distress.  HEENT:  No lymphadenopathy or mucositis.  CARDIOVASCULAR:  Regular rate and rhythm.  LUNGS:  Clear to auscultation bilaterally.  EXTREMITIES:  No cyanosis, clubbing or edema.  NEUROLOGICAL:  No focal deficits noted.  PELVIC:  Normal-appearing external genitalia.  Vaginal vault with no masses or bleeding.,LABORATORY DATA: , None today.,RADIOLOGIC DATA: , CT of the chest, abdomen, and pelvis from 01/28/08 revealed status post total abdominal hysterectomy/bilateral salpingo-oophorectomy with an unremarkable vaginal cuff.  No local or distant metastasis.  Right probably chronic gonadal vein thrombosis.,ASSESSMENT: , This is a 67-year-old white female with history of uterine papillary serous carcinoma, status post total abdominal hysterectomy and bilateral salpingo-oophorectomy and 6 cycles of carboplatin and Taxol chemotherapy.  She is doing well with no evidence of disease clinically or radiologically.,PLAN:,1.  Plan to follow her every 3 months and CT scans every 6 months for the first 2 years.,2.  The patient was advised to contact the primary physician for repeat blood pressure check and get started on antihypertensives if it is persistently elevated.,3.  The patient was told that the mole that she is mentioning in her head is no longer palpable and just to observe it for now.,4.  The patient was advised about doing Kegel exercises for urinary incontinence, and we will address this issue again during next clinic visit if it is persistent.,
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DESCRIPTION: The patient is a 67-year-old white female with a history of uterine papillary serous carcinoma who is status post 6 cycles of carboplatin and Taxol, is here today for followup.

hematology - oncology, chemotherapy, uterine papillary serous carcinoma, oophorectomy, carboplatin, taxol, abdominal, uterine, papillary, carcinoma,

The scenario involves a follow-up visit for a patient who has been treated for uterine papillary serous carcinoma, indicating she is in remission post-surgery and chemotherapy. The primary concerns now relate to non-critical issues such as mild hypertension and a mole that is no longer palpable. No current evidence of cancer recurrence or significant health crises is present. However, monitoring the patient for recurring cancer and other health issues is crucial, though not high-stakes at this time given the patient's current stable condition.


Medical Specialty: Surgery
Sample Name: Heart Catheterization, Ventriculography, & Angiography - 7

PROCEDURE: , Left heart catheterization, coronary angiography, left ventriculography.,COMPLICATIONS: , None.,PROCEDURE DETAIL: , The right femoral area was draped and prepped in the usual fashion after Xylocaine infiltration.  A 6-French arterial sheath was placed in the usual fashion.  Left and right coronary angiograms were then performed in various projections after heparin was given 2000 units intraaortic.  The right coronary artery was difficult to cannulate because of its high anterior takeoff.  This was nondominant.  Several catheters were used.  Ultimately, an AL1 diagnostic catheter was used.  A pigtail catheter was advanced across the aortic valve.  Left ventriculogram was then done in the RAO view using 30 mL of contrast.  Pullback gradient was obtained across the aortic valve.  Femoral angiogram was performed through the sheath which was above the bifurcation, was removed with a Perclose device with good results.  There were no complications.  He tolerated this procedure well and returned to his room in good condition.,FINDINGS,1.  Right coronary artery:  This has an unusual high anterior takeoff.  The vessel is nondominant, has diffuse mild-to-moderate disease.,2.  Left main trunk:  A 30% to 40% distal narrowing is present.,3.  Left anterior descending:  Just at the ostium of the vessel and up to and including the bifurcation of the first large diagonal branch, there is 80 to 90% narrowing.  The diagonal is a large vessel about 3 mm in size.,4.  Circumflex:  Dominant vessel, 50% narrowing at the origin of the obtuse marginal.  After this, there is 40% narrowing in the AV trunk.  The small posterior lateral branch has diffuse mild disease and then the vessel gives rise to a fairly large posterior ventricular branch, which has 70% ostial narrowing, and then after this the posterior descending has 80% narrowing at its origin.,5.  Left ventriculogram:  Normal volume in diastole and systole.  Normal systolic function is present.  There is no mitral insufficiency or left ventricular outflow obstruction.,DIAGNOSES,1.  Severe complex left anterior descending and distal circumflex disease with borderline, probably moderate narrowing of a large obtuse marginal branch.  Dominant circumflex system.  Severe disease of the posterior descending.  Mild left main trunk disease.,2.  Normal left ventricular systolic function.,Given the complex anatomy of the predominant problem which is the left anterior descending; given its ostial stenosis and involvement of the bifurcation of the diagonal, would recommend coronary bypass surgery.  The patient also has severe disease of the circumflex which is dominant.  This anatomy is not appropriate for percutaneous intervention.  The case will be reviewed with a cardiac surgeon.
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DESCRIPTION: Left heart catheterization, coronary angiography, left ventriculography.  Severe complex left anterior descending and distal circumflex disease with borderline, probably moderate narrowing of a large obtuse marginal branch.

surgery, heart catheterization, coronary angiography, left ventriculography, arterial sheath, coronary artery, obtuse marginal branch, angiography, catheterization,

The situation involves a complex cardiac procedure with critical diagnoses, particularly involving the left anterior descending and circumflex arteries, which are crucial for heart function. The findings suggest severe coronary artery disease, and the recommendation for coronary bypass surgery indicates the seriousness of the condition. Such cases require careful decision-making and have significant implications for the patient's health outcome, thus making it a high-stakes scenario.


Medical Specialty: Neurology
Sample Name: Neuro Consult - Depression & Dementia

Subsequently, the patient developed a moderately severe depression.  She was tried on various medications, which caused sweating, nightmares and perhaps other side effects.  She was finally put on Effexor 25 mg two tablets h.s. and trazodone 100 mg h.s., and has done fairly well, although she still has significant depression.,Her daughter brought her in today to be sure that she does not have dementia.  There is no history of memory loss.  There is no history of focal neurologic symptoms or significant headaches.,The patient's complaints, according to the daughter, include not wanted to go out in public, shamed regarding her appearance (25-pound weight loss over the past year), eating poorly, not doing things unless asked, hiding food to prevent having to eat it, nervousness, and not taking a shower.  She has no focal neurologic deficits.  She does complain of constipation.  She has severe sleep maintenance insomnia and often sleeps only 2 hours before awakening frequently for the rest of the night.,The patient was apparently visiting her daughter in northern California in December 2003.  She was taken to her daughter's primary care physician.  She underwent vitamin B12 level, RPR, T4 and TSH, all of which were normal.,On 05/15/04, the patient underwent MRI scan of the brain.  I reviewed the scan in the office today.  This shows moderate cortical and central atrophy and also shows mild-to-moderate deep white matter ischemic changes.,PAST MEDICAL HISTORY: , The patient has generally been in reasonably good physical health.  She did have a "nervous breakdown" in 1975 after the death of her husband.  She was hospitalized for several weeks and was treated with ECT.  This occurred while she was living in Korea.,She does not smoke or drink alcoholic beverages.  She has had no prior surgeries.  There is a past history of hypertension, but this is no longer present.,FAMILY HISTORY: , Negative for dementia.  Her mother died of a stroke at the age of 62.,PHYSICAL EXAMINATION:,Vital Signs:  Blood pressure 128/80, pulse 84, temperature 97.4 F, and weight 105 lbs (dressed).,General:  Well-developed, well-nourished Korean female in no acute distress.,Head:  Normocephalic, without evidence of trauma or bruits.,Neck:  Supple, with full range of motion.  No spasm or tenderness.  Carotid pulsations are of normal volume and contour bilaterally without bruits.  No thyromegaly or adenopathy.,Extremities:  No clubbing, cyanosis, edema, or deformity.  Range of motion full throughout.,NEUROLOGICAL EXAMINATION:,Mental Status:  The patient is awake, alert and oriented to time, place, and person and generally appropriate.  She exhibits mild psychomotor retardation and has a flat or depressed affect.  She knows the current president of Korea and the current president of the United States.  She can recall 3 out of 3 objects after 5 minutes.  Calculations are performed fairly well with occasional errors.  There is no right-left confusion, finger agnosia, dysnomia or aphasia.,Cranial Nerves:,II:
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DESCRIPTION:

The scenario involves a complex medical case with a patient showing symptoms of depression and a potential risk of dementia. Proper diagnosis and management are crucial as they affect the patient's quality of life and mental health. Misdiagnosis could lead to inappropriate treatment, worsening the patient's condition. Therefore, the situation holds significant importance for the patient's current and future well-being.


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

Medical Specialty: Urology
Sample Name: Circumcision - 4

The patient tolerated the procedure well and was sent to the Recovery Room in stable condition.
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DESCRIPTION: Normal Circumcision

Normal Circumcision

urology, circumcision, circumferential proximal incisions, hemostasis, vaseline soaked gauze, catgut, foreskin, needlepoint bovie, pain block, shaft of the penis, supine position, penisNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.

The situation describes a patient undergoing a routine circumcision procedure in the field of urology. The description indicates that the procedure was normal and the patient was sent to recovery in stable condition. As a routine procedure with a typical outcome and no mention of complications, it is considered relatively low-stakes in the medical context.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Chest Tube Insertion

PREOPERATIVE DIAGNOSIS: , Right hemothorax.,POSTOPERATIVE DIAGNOSIS: , Right hemothorax.,PROCEDURE PERFORMED: , Insertion of a #32 French chest tube on the right hemithorax.,ANESTHESIA: , 1% Lidocaine and sedation.,INDICATIONS FOR PROCEDURE:,  This is a 54-year-old female with a newly diagnosed carcinoma of the cervix.  The patient is to have an Infuse-A-Port insertion today.  Postoperatively from that, she started having a blood tinged pink frothy sputum.  Chest x-ray was obtained and showed evidence of a hemothorax on the right hand side, opposite side of the Infuse-A-Port and a wider mediastinum.  The decision was made to place a chest tube in the right hemithorax to allow for the patient to be stable for transfer out of the operating room.,DESCRIPTION OF PROCEDURE: , The area was prepped and draped in the sterile fashion.  The area was anesthetized with 1% Lidocaine solution.  The patient was given sedation.  A #10 blade scalpel was used to make an incision approximately 1.5 cm long.  Then a curved scissor was used to dissect down to the level of the rib.  A blunt peon was then used to again enter into the right hemithorax.  Immediately a blood tinged effusion was released.  The chest tube was placed and directed in a posterior and superior direction.  The chest tube was hooked up to the Pleur-evac device which was ________ tip suction.  The chest tube was tied in with a #0 silk suture in a U-stitch fashion.  It was sutured in place with sterile dressing and silk tape.  The patient tolerated this procedure well.  We will obtain a chest x-ray in postop to ensure proper placement and continue to follow the patient very closely.
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DESCRIPTION: Right hemothorax.  Insertion of a #32 French chest tube on the right hemithorax.  This is a 54-year-old female with a newly diagnosed carcinoma of the cervix.  The patient is to have an Infuse-A-Port insertion.

cardiovascular / pulmonary, hemothorax, hemithorax, pleur-evac device, infuse-a-port insertion, chest tube, carcinoma

Chest tube insertion for a hemothorax in a patient with newly diagnosed cervical carcinoma is a high-stakes situation. Complications such as hypoxia, infection, or needle injuries could arise, impacting patient outcomes significantly. The scenario involves critical decision-making and immediate intervention to ensure patient stabilization and proper management of the underlying condition. The stakes are further elevated due to the patient's cancer diagnosis, which can complicate recovery and treatment.


Medical Specialty: Pediatrics - Neonatal
Sample Name: Fundoplication & Gastrostomy Followup

REASON FOR VISIT: , Followup of laparoscopic fundoplication and gastrostomy.,HISTORY OF PRESENT ILLNESS: , The patient is a delightful baby girl, who is now nearly 8 months of age and had a tracheostomy for subglottic stenosis.  Laparoscopic fundoplication and gastrostomy was done because of the need for enteral feeding access and to protect her airway at a time when it is either going to heal enough to improve and allow decannulation or eventually prove that she will need laryngotracheoplasty.  Dr. X is following The patient for this and currently plans are to perform a repeat endoscopic exam every couple of months to assist the status of her airway caliber.,The patient had a laparoscopic fundoplication and gastrostomy on 10/05/2007.  She has done well since that time.  She has had some episodes of retching intermittently and these seemed to be unpredictable.  She also had some diarrhea and poor feeding tolerance about a week ago but that has also resolved.  The patient currently takes about 1 ounce to 1.5 ounce of her feedings by mouth and the rest is given by G-tube.  She seems otherwise happy and is not having an excessive amount of stools.  Her parents have not noted any significant problems with the gastrostomy site.,The patient's exam today is excellent.  Her belly is soft and nontender.  All of her laparoscopic trocar sites are healing with a normal amount of induration, but there is no evidence of hernia or infection.  We removed The patient's gastrostomy button today and showed her parents how to reinsert one without difficulty.  The site of the gastrostomy is excellent.  There is not even a hint of granulation tissue or erythema, and I am very happy with the overall appearance.,IMPRESSION: , The patient is doing exceptionally well status post laparoscope fundoplication and gastrostomy.  Hopefully, the exquisite control of acid reflux by fundoplication will help her airway heal, and if she does well, allow decannulation in the future.  If she does require laryngotracheoplasty, the protection from acid reflux will be important to healing of that procedure as well.,PLAN:  ,The patient will follow up as needed for problems related to gastrostomy.  We will see her when she comes in the hospital for endoscopic exams and possibly laryngotracheoplasty in the future.
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DESCRIPTION: Followup of laparoscopic fundoplication and gastrostomy.  Laparoscopic fundoplication and gastrostomy was done because of the need for enteral feeding access.

pediatrics - neonatal, decannulation, enteral feeding, feeding access, laparoscopic fundoplication, gastrostomy, airway, laryngotracheoplasty, laparoscopic, fundoplication,

The situation involves follow-up care for a baby who underwent significant surgical procedures (laparoscopic fundoplication and gastrostomy) to manage her medical conditions, including subglottic stenosis and the need for enteral feeding. The success of these procedures and monitoring impacts her current and future health significantly, including potential decannulation and avoidance of further surgery such as laryngotracheoplasty. While she currently appears to be doing well, the follow-ups are crucial for managing her condition and preventing future complications. The case involves complex medical care for an infant, but current exam findings are positive and no immediate acute issues are present.


Medical Specialty: Surgery
Sample Name: Rectovaginal Fistula Closure

PREOPERATIVE DIAGNOSIS (ES):, Rectovaginal fistula.,POSTOPERATIVE DIAGNOSIS (ES):, Rectovaginal fistula.,PROCEDURE:, CPT code 57307 - Closure of rectovaginal fistula, transperineal approach.,MATERIAL FORWARDED TO THE LABORATORY FOR EXAMINATION:, Includes fistula tract.,ESTIMATED BLOOD LOSS:, 25 mL.,INDICATIONS:, The patient is a 27-year-old morbidly obese gravida three, para one, who was seen in consultation from Dr. M's office, in the office of Chattanooga GYN Oncology on 01/12/06 regarding an obstetrically related rectovaginal fistula, dating from 1998. She had an episioproctotomy associated with the birth of her seven pound son in 1998 and immediately noted the spontaneous loss of gas and stool. She had her fistula repaired by Dr. R in 2000 and did well for approximately one year, without complaint, when she again noted the spontaneous loss of stool and gas from her vagina. She has partial control if her stools are formed, but she has no control of her gas. She is a type 2 diabetic, with poorly controlled blood sugars at times, however, her diabetes has been fairly well controlled of late.,FINDINGS AT THE TIME OF SURGERY:, She had a 1 cm fistulous tract, approximately 4 cm proximal to the vaginal introitus. This communicated directly with the low rectal vault. She had good rectal sphincter tone and a very thin perineal body. The fistulous tract was excised completely and intact. The underlying rectal mucosa was closed with chromic and the perineal body was reinforced and reconstructed. At the completion of the procedure, the repair is watertight, there were no other defects.,DESCRIPTION OF THE OPERATION:, The patient was taken to the operating room where she underwent general endotracheal anesthesia. She was then placed in the lithotomy position using candy-cane stirrups. The vulva and vagina were prepped and the patient was draped. A lacrimal duct probe was used to define the fistulous tract and a transperineal incision was made. The rectovaginal septum was developed and with an index finger in the rectum, the rectovaginal septum was easily defined. The fistulous tract was isolated and using the lacrimal duct probe, it was completely isolated. Using electrocautery dissection on the pure cut mode, the rectal mucosa was entered in a circumferential fashion as was the vaginal mucosa. This allowed for removal of the fistulous tract intact, with both epithelial layers preserved. The perineum and rectum were irrigated vigorously and then the rectal mucosa was reapproximated with a running stitch of number 4-0 chromic. The rectal vault was distended with saline and the repair was watertight. The defect was irrigated, suctioned, inspected and found to be free of clot, blood or debris. The perineal body was reconstructed with reapproximation of the levator muscles, using a series of interrupted horizontal mattress stitches of number 2-0 Vicryl. This allowed for excellent restoration of the perineal body. After this was accomplished, the defect was once again irrigated, suctioned, inspected, and found to be free of clot, blood or debris. The vaginal defect was closed with a running locking stitch of number 2-0 Vicryl and the perineal incision was closed with a subcuticular stitch of number 2-0 Vicryl. The patient was awakened and taken to the recovery room in stable condition, after having tolerated the procedure well.
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DESCRIPTION: Closure of rectovaginal fistula, transperineal approach

surgery, transperineal approach, fistula tract, fistula, rectovaginal, septum, lacrimal duct, probe, candy-cane, perineal, closure of rectovaginal fistula, rectal mucosa, perineal body, fistulous tract, rectovaginal fistula, transperineal, fistulous, rectal,

This medical procedure involves the surgical closure of a rectovaginal fistula, which could significantly impact the patient's quality of life due to symptoms like incontinence and spontaneous passage of gas and stool. Although not immediately life-threatening, the procedure is complex and complications could significantly affect the patient's postoperative well-being. Therefore, it is considered moderately high-stakes due to potential complications affecting the patient's daily life, recovery, and the necessity of surgical correction to restore normal function.


Medical Specialty: Cosmetic / Plastic Surgery
Sample Name: Mammoplasty - 2

PREOPERATIVE DIAGNOSES,Breast hypoplasia, melasma to the face, and varicose veins to the posterior aspect of the right distal thigh/popliteal fossa area.,PROCEDURES,1.  Bilateral augmentation mammoplasty, subglandular with a mammary gel silicone breast implant, 435 cc each.,2.  TCA peel to two lesions of the face and vein stripping to the right posterior thigh and popliteal fossa area.,ANESTHESIA,General endotracheal.,EBL,100 cc.,IV FLUIDS,2L.,URINE OUTPUT,Per Anesthesia.,INDICATION FOR SURGERY,The patient is a 48-year-old female who was seen in clinic by Dr. W and where she was evaluated for her small breasts as well as dark areas on her face and varicose veins to the back and posterior aspect of her right lower extremity.  She requested that surgical procedures to be performed for correction of these abnormalities.  As such, complications were explained to the patient including infection, bleeding, poor wound healing, and need for additional surgery.  The patient subsequently signed the consent and requested that Dr. W and associates to perform the procedure.,TECHNIQUE,The patient was brought to the operating room in supine position.  General anesthesia was induced and then the patient was placed on the operating table in a prone position.  The posterior thigh of the right lower extremity was prepped and draped in a sterile fashion.  First, multiple serial small incisions less than 1 cm in length were made to the posterior aspect of the right thigh and sequential stripping of the varicose veins was performed.  Once these varicose veins had been completely stripped and avulsed, then next the wounds were then irrigated and were cleaned with wet and dry, and all the incisions were closed with the use of 5-0 Monocryl buried interrupted sutures.  The incisions were then dressed with Mastisol, Steri-Strips, ABDs and a TED hose.  Next, the patient was then flipped back over onto the stretcher and placed on the operating table in a supine position.  The anterior chest was then prepped and draped in a sterile fashion.  Next, a 10 blade was placed through previous circumareolar incisions from a previous augmentation mammoplasty.  Dissection was carried out with a 10 blade and Bovie cautery until the pectoralis fascia was identified to both breasts.  Once the pectoralis muscle and fascia were identified, then a surgical plane was created in a subglandular layer.  The hemostasis was obtained to both breast pockets with the Bovie cautery and suction and irrigation was performed to bilateral breast pockets as well.  A sizer was used to identify the appropriate size of the silicone implant to be used.  This was determined to be approximately 435 cc bilaterally.  As such, two mammary gel silicone breast implants were placed in a subglandular muscle.  Additional dissection of the breast pockets were performed bilaterally and the patient was sequentially placed in the upright sitting position for evaluation of appropriate placement of the mammary gel silicone implants.  Once it was determined that the implants were appropriately selected and placed with the 435 cc silicon gel implant, the circumareolar incisions were closed in approximately 4-layered fashion closing the fascia, subcutaneous tissue, deep dermis, and a running dermal subcuticular for final skin closure.  This was performed with 3-0 Monocryl and then 4-0 Monocryl for running subcuticular.  The incisions were then dressed with Mastisol, Steri-Strips, and Xeroform and dressed with sample Kerlix.  Next, our attention was paid to the face where 25% TCA solution was applied to two locations; one on the left cheek and the other one on the right cheek, where a hyperpigmentation/melasma.  Several applications of the TCA peel was performed, and at the end of this, the frosting was noted to both spots.  At the end of the case, needle and instrument counts were correct.  Dr. W was present and scrubbed for the entire procedure.  The patient was extubated in the operating room and taken to the PACU in stable condition.
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DESCRIPTION: Bilateral augmentation mammoplasty, breast implant, TCA peel to lesions, vein stripping.

cosmetic / plastic surgery, breast hypoplasia, monocryl, pacu, tca, tca peel, ted hose, augmentation mammoplasty, breast implant, melasma, poor wound healing, popliteal fossa area, prepped and draped, silicone, varicose vein, vein stripping, mastisol steri strips, steri strips, circumareolar incisions, mammary gel, varicose veins, augmentation, breast, circumareolar, incisions, mammoplasty, mastisol, strips

The described scenario is a comprehensive cosmetic surgery procedure involving bilateral augmentation mammoplasty, facial treatment for melasma using a TCA peel, and varicose vein stripping. While these procedures are elective and primarily for aesthetic purposes, they still involve significant surgical intervention under general anesthesia. There are inherent risks such as infection, complications from anesthesia, bleeding, and poor wound healing. Additionally, mammoplasty and vein stripping can be complex, with potential for complications that can affect the patient's health and well-being. However, the emergency and life-threatening nature of such procedures are typically lower compared to surgeries addressing life-threatening conditions. The stakes are moderate-high given the complexity and multiple procedures involved during a single surgery session.


Medical Specialty: Radiology
Sample Name: Echocardiography

REASON FOR EXAM:,  CVA.,INDICATIONS: , CVA.,This is technically acceptable.  There is some limitation related to body habitus.,DIMENSIONS:  ,The interventricular septum 1.2, posterior wall 10.9, left ventricular end-diastolic 5.5, and end-systolic 4.5, the left atrium 3.9.,FINDINGS: , The left atrium was mildly dilated.  No masses or thrombi were seen.  The left ventricle showed borderline left ventricular hypertrophy with normal wall motion and wall thickening, EF of 60%.  The right atrium and right ventricle are normal in size.,Mitral valve showed mitral annular calcification in the posterior aspect of the valve.  The valve itself was structurally normal.  No vegetations seen.  No significant MR. Mitral inflow pattern was consistent with diastolic dysfunction grade 1.  The aortic valve showed minimal thickening with good exposure and coaptation.  Peak velocity is normal.  No AI.,Pulmonic and tricuspid valves were both structurally normal.,Interatrial septum was appeared to be intact in the views obtained.  A bubble study was not performed.,No pericardial effusion was seen.  Aortic arch was not assessed.,CONCLUSIONS:,1.  Borderline left ventricular hypertrophy with normal ejection fraction at 60%.,2.  Mitral annular calcification with structurally normal mitral valve.,3.  No intracavitary thrombi is seen.,4.  Interatrial septum was somewhat difficult to assess, but appeared to be intact on the views obtained.
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DESCRIPTION: Echocardiographic examination.  Borderline left ventricular hypertrophy with normal ejection fraction at 60%, mitral annular calcification with structurally normal mitral valve, no intracavitary thrombi is seen, interatrial septum was somewhat difficult to assess, but appeared to be intact on the views obtained.

radiology, ventricular hypertrophy, normal wall motion, ventricle, atrium, annular calcification, mitral valve, interatrial septum, hypertrophy, annular, thrombi, ventricular, structurally, septum, valve, mitral,

The situation involves an echocardiography report primarily used for assessing cardiac structures and functionality. The findings indicate some concerns like borderline left ventricular hypertrophy and mitral annular calcification, but overall no critical issues such as significant valve dysfunction or thrombi are reported. These findings do not suggest an immediate life-threatening condition, but they do inform patient management and potential future interventions. Therefore, this can be considered a medium-stakes situation based on the current findings.


Medical Specialty: Neurology
Sample Name: Craniotomy - Occipital

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

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

The procedure described is a complex neurosurgical operation involving the removal of brain tumors. Such surgeries carry significant risks, including potential complications like infection, bleeding, and neurological deficits. The stakes are further heightened by the patient's condition, which involves multiple brain tumors and metastasis from breast cancer, indicating a serious and life-threatening medical situation. The operation's success is critical for the patient's immediate well-being and long-term health outcomes. Therefore, the situation is high-stakes both medically and personally for the patient.


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

Thereafter, he was evaluated and it was felt that further reconstruction as related to the anterior cruciate ligament was definitely not indicated.  On December 5, 2008, Mr. XXXX did undergo a total knee replacement arthroplasty performed by Dr. X.,Thereafter, he did an extensive course of physical therapy, work hardening, and a work conditioning type program.,At the present time, he does complain of significant pain and swelling as related to the right knee.  He is unable to crawl and/or kneel.  He does state he is able to walk a city block and in fact, he is able to do 20 minutes of a treadmill.  Stairs are a significant problem.  His pain is a 5 to 6 on a scale of 1 to 10.,He is better when he is resting, sitting, propped up, and utilizing his ice.  He is much worse when he is doing any type of physical activity.,He has denied having any previous history of similar problems.,CURRENT MEDICATIONS:  ,Over-the-counter pain medication.,ALLERGIES: , NKA.,SURGERIES: , Numerous surgeries as related to the right lower extremity.,SOCIAL HISTORY: , He does admit to one half pack of cigarette consumption per day.  He denies any alcohol consumption.,PHYSICAL EXAMINATION:  ,On examination today, he is 28-year-old male who is 6 feet 1, weighs 250 pounds.  He does not appear to be in distress at this time.  One could appreciate 1-2/4 intraarticular effusion.  The range of motion is 0 to a 110 degrees of flexion.  I could not appreciate any evidence of instability medial, lateral, anterior or posterior.  Crepitus is noted with regards to range of motion testing.  His strength is 4 to 5 as related to the quadriceps and hamstring.,There is atrophy as related to the right thigh.  The patient is able to stand from a seated position and sit from a standing position without difficulty.,RECORDS REVIEW:,1.  First report of injury.,2.  July 17, 2002, x-rays of the right knee were negative.,3.  Notes of the Medina General Hospital Occupational Health, Steven Rodgers, M.D.,4.  August 5, 2002, an MRI scan of the right knee which demonstrated peripheral tear of the posterior horn of the medial
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DESCRIPTION: Patient did undergo surgical intervention as related to the right knee and it was noted that the reconstruction had failed.   A screw had come loose.

The situation involves a patient's orthopedic history and current condition following knee surgery and replacement. While the patient experiences significant discomfort and limitations (pain rated 5 to 6 out of 10 and difficulty with stairs), the stakes are not immediately life-threatening. The patient also has a history of extensive physical therapy and previous surgeries, something common in orthopedic cases. The condition affects the patient's quality of life, but there is no acute threat to health requiring emergency intervention. The stakes are moderate primarily due to the patient's ongoing pain and reduced mobility, which could impact daily activities and overall well-being.


Medical Specialty: Orthopedic
Sample Name: Subcutaneous Transposition of Ulnar Nerve

PREOPERATIVE DIAGNOSIS:  ,1.  Right carpal tunnel syndrome.,2.
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DESCRIPTION: Subcutaneous transposition of the right ulnar nerve.  Right carpal tunnel syndrome and right cubital tunnel syndrome.

orthopedic, subcutaneous transposition, ulnar nerve, carpal tunnel syndrome, cubital tunnel syndrome, tourniquet, subcutaneous, epicondyle, antebrachial, syndrome, cubital, ulnar, nerve, tunnel

The situation involves a surgical procedure of subcutaneous transposition of the ulnar nerve, which is a significant medical procedure dealing with nerve issues such as carpal tunnel syndrome and cubital tunnel syndrome. These conditions affect nerve functionality and can seriously impair a patient's quality of life if untreated. Therefore, while the procedure is routine in orthopedic surgery, it still carries typical surgical risks such as infection, nerve damage, and complications from anesthesia. The stakes are higher than minor medical treatments, marking it as reasonably high-stakes in the context of surgical procedures.