Medical Specialty: Neurology
Sample Name: Alzheimer Disease

CC:, Memory difficulty.,HX: ,This 64 y/o RHM had had difficulty remembering names, phone numbers and events for 12 months prior to presentation, on 2/28/95. This had been called to his attention by the clerical staff at his parish--he was a Catholic priest. He had had no professional or social faux pas or mishaps due to his memory. He could not tell whether his problem was becoming worse, so he brought himself to the Neurology clinic on his own referral.,MEDS:, None.,PMH: ,1)appendectomy, 2)tonsillectomy, 3)childhood pneumonia, 4)allergy to sulfa drugs.,FHX:, Both parents experienced memory problems in their ninth decades, but not earlier. 5 siblings have had no memory trouble. There are no neurological illnesses in his family.,SHX:, Catholic priest. Denied Tobacco/ETOH/illicit drug use.,EXAM:,  BP131/74, HR78, RR12, 36.9C, Wt. 77kg, Ht. 178cm.,MS: A&O to person, place and time. 29/30 on MMSE; 2/3 recall at 5 minutes. 2/10 word recall at 10 minutes. Unable to remember the name of the President (Clinton). 23words/60 sec on Category fluency testing (normal). Mild visual constructive deficit.,The rest of the neurologic exam was unremarkable and there were no extrapyramidal signs or primitive reflexes noted.,COURSE:, TSH 5.1, T4 7.9, RPR non-reactive. Neuropsychological evaluation, 3/6/95, revealed: 1)well preserved intellectual functioning and orientation, 2) significant deficits in verbal and visual memory, proper naming, category fluency and working memory, 3)performances which were below expectations on tests of speed of reading, visual scanning, visual construction and clock drawing, 4)limited insight into the scope and magnitude of cognitive dysfunction. The findings indicated multiple areas of cerebral dysfunction. With the exception of the patient's report of minimal occupational dysfunction ( which may reflect poor insight), the clinical picture is consistent with a progressive dementia syndrome such as Alzheimer's disease. MRI brain, 3/6/95, showed mild generalized atrophy, more severe in the occipital-parietal regions.,In 4/96, his performance on repeat neuropsychological evaluation was relatively stable. His verbal learning and delayed recognition were within normal limits, whereas delayed recall was "moderately severely" impaired. Immediate and delayed visual memory were slightly below expectations. Temporal orientation and expressive language skills were below expectation, especially in word retrieval. These findings were suggestive of particular, but not exclusive, involvement of the temporal lobes.,On 9/30/96, he was evaluated for a 5 minute spell of visual loss, OU. The episode occurred on Friday, 9/27/96, in the morning while sitting at his desk doing paperwork. He suddenly felt that his gaze was pulled toward a pile of letters; then a "curtain" came down over both visual fields, like "everything was in the shade." During the episode he felt fully alert and aware of his surroundings. He concurrently heard a "grating sound" in his head. After the episode, he made several phone calls, during which he reportedly sounded confused, and perseverated about opening a bank account. He then drove to visit his sister in Muscatine, Iowa, without accident. He was reportedly "normal" when he reached her house. He was able to perform Mass over the weekend without any difficulty. Neurologic examination, 9/30/96, was notable for: 1)category fluency score of 18items/60 sec. 2)VFFTC and EOM were intact. There was no RAPD, INO, loss of visual acuity. Glucose 178 (elevated), ESR ,Lipid profile, GS, CBC with differential, Carotid duplex scan, EKG, and EEG were all normal. MRI brain, 9/30/96, was unchanged from previous, 3/6/95.,On 1/3/97, he had a 30 second spell of lightheadedness without vertigo, but with balance difficulty, after picking up a box of books. The episode was felt due to orthostatic changes.,1/8/97 neuropsychological evaluation was stable and his MMSE score was 25/30 (with deficits in visual construction, orientation, and 2/3 recall at 1 minute). Category fluency score 23 items/60 sec. Neurologic exam was notable for graphesthesia in the left hand.,In 2/97, he had episodes of anxiety, marked fluctuations in job performance and resigned his pastoral position. His neurologic exam was unchanged. An FDG-PET scan on 2/14/97 revealed decreased uptake in the right posterior temporal-parietal and lateral occipital regions.
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DESCRIPTION: MRI brain & PET scan - Dementia of Alzheimer type with primary parietooccipital involvement.

neurology, dementia, a&o to person, alzheimer's disease, alzheimer's type, mmse, mmse score, mri brain, memory difficulty, neuropsychological, balance difficulty, category fluency, faux pas, minimal occupational dysfunction, parieto-occipital, progressive dementia syndrome, visual acuity, visual loss, visual memory, pet scan, neuropsychological evaluation, alzheimer's, neurological, memory,

The patient is experiencing cognitive decline consistent with Alzheimer's disease, a progressive and serious condition affecting memory and other critical cognitive functions. While the patient's life is not immediately at risk, the stakes are high because Alzheimer's is a degenerative disease that affects the patient's quality of life and independence, and requires significant medical attention and possibly long-term care planning. The situation also involves diagnostic procedures such as MRI and PET scans to assess brain involvement, indicative of the complexity and seriousness of the condition.


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

Medical Specialty: Orthopedic
Sample Name: Lumbar Laminectomy & Discectomy

PREOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus, L5-S1 on the left with severe weakness and intractable pain.,POSTOPERATIVE DIAGNOSIS:,  Herniated nucleus pulposus, L5-S1 on the left with severe weakness and intractable pain.,PROCEDURE PERFORMED:,1.  Injection for myelogram.,2.  Microscopic-assisted lumbar laminectomy with discectomy at L5-S1 on the left on 08/28/03.,BLOOD LOSS: , Approximately 25 cc.,ANESTHESIA: , General.,POSITION:,  Prone on the Jackson table.,INTRAOPERATIVE FINDINGS:,  Extruded nucleus pulposus at the level of L5-S1.,HISTORY: , This is a 34-year-old male with history of back pain with radiation into the left leg in the S1 nerve root distribution.  The patient was lifting at work on 08/27/03 and felt immediate sharp pain from his back down to the left lower extremity.  He denied any previous history of back pain or back surgeries.  Because of his intractable pain as well as severe weakness in the S1 nerve root distribution, the patient was aware of all risks as well as possible complications of this type of surgery and he has agreed to pursue on.  After an informed consent was obtained, all risks as well as complications were discussed with the patient.  ,PROCEDURE DETAIL:  ,He was wheeled back to Operating Room #5 at ABCD General Hospital on 08/28/03.  After a general anesthetic was administered, a Foley catheter was inserted.,The patient was then turned prone on the Jackson table.  All of his bony prominences were well-padded.  At this time, a myelogram was then performed.  After the lumbar spine was prepped, a #20 gauge needle was then used to perform a myelogram.  The needle was localized to the level of L3-L4 region.  Once inserted into the thecal sac, we immediately got cerebrospinal fluid through the spinal needle.  At this time, approximately 10 cc of Conray injected into the thecal sac.  The patient was then placed in the reversed Trendelenburg position in order to assist with distal migration of the contrast.  The myelogram did reveal that there was some space occupying lesion, most likely disc at the level of L5-S1 on the left.  There was a lack of space filling defect on the left evident on both the AP and the lateral projections using C-arm fluoroscopy.  At this point, the patient was then fully prepped and draped in the usual sterile fashion for this procedure for a microdiscectomy.  A long spinal needle was then inserted into region of surgery on the right.  The surgery was going to be on the left.  Once the spinal needle was inserted, a localizing fluoroscopy was then used to assure appropriate location and this did confirm that we were at the L5-S1 nerve root region.  At this time, an approximately 2 cm skin incision was made over the lumbar region, dissected down to the deep lumbar fascia.  At this time, a Weitlaner was inserted.  Bovie cautery was used to obtain hemostasis.  We further continued through the deep lumbar fascia and dissected off the short lumbar muscles off of the spinous process and the lamina.  A Cobb elevator was then used to elevate subperiosteally off of all the inserting short lumbar muscles off of the spinous process as well as the lamina on the left-hand side.  At this time, a Taylor retractor was then inserted and held there for retraction.  Suction as well as Bovie cautery was used to obtain hemostasis.  At this time, a small Kerrison Rongeur was used to make a small lumbar laminotomy to expose our window for the nerve root decompression.  Once the laminotomy was performed, a small _______ curette was used to elevate the ligamentum flavum off of the thecal sac as well as the adjoining nerve roots.  Once the ligamentum flavum was removed, we immediately identified a piece of disc material floating around outside of the disc space over the S1 nerve root, which was compressive.  We removed the extruded disc with further freeing up of the S1 nerve root.  A nerve root retractor was then placed.  Identification of disc space was then performed.  A #15 blade was then inserted and small a key hole into the disc space was then performed with a #15 blade.  A small pituitary was then inserted within the disc space and more disc material was freed and removed.  The part of the annulus fibrosis were also removed in addition to the loose intranuclear pieces of disc.  Once this was performed, we removed the retraction off the nerve root and the nerve root appeared to be free with pulsatile visualization of the vasculature indicating that the nerve root was essentially free.,At this time, copious irrigation was used to irrigate the wound.  We then performed another look to see if any loose pieces of disc were extruding from the disc space and only small pieces were evident and they were then removed with the pituitary rongeur.  At this time, a small piece of Gelfoam was then used to cover the exposed nerve root.  We did not have any dural leaks during this case.  #1-0 Vicryl was then used to approximate the deep lumbar fascia, #2-0 Vicryl was used to approximate the superficial lumbar fascia, and #4-0 running Vicryl for the subcutaneous skin.  Sterile dressings were then applied.  The patient was then carefully slipped over into the supine position, extubated and transferred to Recovery in stable condition.  At this time, we are still waiting to assess the patient postoperatively to assure no neurological sequela postsurgically are found and also to assess his pain level.
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DESCRIPTION: Injection for myelogram and microscopic-assisted lumbar laminectomy with discectomy at L5-S1 on the left.  Herniated nucleus pulposus, L5-S1 on the left with severe weakness and intractable pain.

orthopedic, microscopic-assisted lumbar laminectomy, discectomy, nerve root, lumbar laminectomy, herniated nucleus, thecal sac, spinal needle, nucleus pulposus, disc space, root, nerve, weakness, lumbar, laminectomy, nucleus, pulposus, myelogram

Lumbar laminectomy and discectomy are surgical procedures performed to relieve pain and neurological symptoms associated with a herniated disc. The stakes of this surgery are significant, as it involves operating near the spine and nerves, with potential risks including nerve damage, infection, or complications with anesthesia. The patient presented with severe symptoms like intractable pain and weakness, necessitating surgical intervention. While routine for experienced surgeons, the procedure's outcomes are crucial for the patient's recovery and quality of life.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Consult - History and Phy.
Sample Name: Marginal Zone Lymphoma

CHIEF COMPLAINT: , Marginal zone lymphoma.,HISTORY OF PRESENT ILLNESS: , This is a very pleasant 46-year-old woman, who I am asked to see in consultation for a newly diagnosed marginal zone lymphoma (MALT-type lymphoma).  A mass was found in her right breast on physical examination.  On 07/19/10, she had a mammogram and ultrasound, which confirmed the right breast mass.  On 07/30/10, she underwent a biopsy, which showed a marginal zone lymphoma (MALT-type lymphoma).,Overall, she is doing well.  She has a good energy level and her ECOG performance status is 0.  She denies any fevers, chills, or night sweats.  No lymphadenopathy.  No nausea or vomiting.  She has normal bowel and bladder habits.  No melena or hematochezia.,CURRENT MEDICATIONS:  ,Macrobid 100 mg q.d.,ALLERGIES:  ,Sulfa, causes nausea and vomiting.,REVIEW OF SYSTEMS: , As per the HPI, otherwise negative.,PAST MEDICAL HISTORY:,1.  She is status post a left partial nephrectomy as a new born.,2.  In 2008 she had a right ankle fracture.,SOCIAL HISTORY: , She has a 20-pack year history of tobacco use.  She has rare alcohol use.  She has no illicit drug use.  She is in the process of getting divorced.  She has a 24-year-old son in the area and 22-year-old daughter.,FAMILY HISTORY:  ,Her mother had uterine cancer.  Her father had liver cancer.,PHYSICAL EXAM:,VIT:
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DESCRIPTION: Marginal zone lymphoma (MALT-type lymphoma).  A mass was found in her right breast on physical examination.  she had a mammogram and ultrasound, which confirmed the right breast mass.

The situation involves a new diagnosis of a hematologic cancer, specifically marginal zone lymphoma (MALT-type lymphoma), which has been identified in the patient's right breast. Cancer diagnoses are generally considered high-stakes due to the potential implications for treatment and prognosis. However, the patient is currently in good health with no adverse symptoms and a performance status of 0, indicating she is physically well. The urgency and severity in this context are moderate because the diagnosis is recent, and the patient is stable and asymptomatic. Nonetheless, the diagnosis of any cancer carries significant weight due to the need for timely and appropriate intervention to manage the disease and its potential impacts on the patient's health and life expectancy.


Medical Specialty: Surgery
Sample Name: Sebaceous Cyst Removal

PREOPERATIVE DIAGNOSIS:,  Infected sebaceous cyst, right neck.,POSTOPERATIVE DIAGNOSIS:,  Infected sebaceous cyst, right neck.,PROCEDURE: , The patient was electively taken to the operating room after obtaining an informed consent.  With a combination of intravenous sedation and local infiltration anesthesia, a time-out process was followed and then the patient was prepped and draped in the usual fashion.  The elliptical incision was performed around the draining tract.  Immediately we fell in to an abscess cavity with a lot of pus and necrotic tissue.  All the necrotic tissue was excised together with an ellipse of skin.  Hemostasis was achieved with a cautery.  The cavity was irrigated with normal saline.  At the end of procedure, there was a good size around cavity that was packed with iodoform gauze.  One skin suture was grazed for approximation.,A bulky dressing was applied.,The patient tolerated the procedure well.  Estimated blood loss was negligible and the patient was sent to Same Day Surgery for recovery.
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DESCRIPTION: Removal of infected sebaceous cyst, right neck.

surgery, infected sebaceous cyst, necrotic tissue, sebaceous cyst, infected

The procedure described is a routine surgical removal of an infected sebaceous cyst on the patient's neck. While it involves an incision and removal of tissue, it is considered a minor surgery with low risk of significant complications. The details provided such as use of IV sedation and local anesthesia, negligible blood loss, and successful recovery indicate it is not high-stakes. It's a common surgical intervention where the patient is typically expected to recover well and quickly.


Medical Specialty: Consult - History and Phy.
Sample Name: Consult - Stasis Ulcer

REASON FOR THE CONSULT:,  Nonhealing right ankle stasis ulcer.,HISTORY OF PRESENT ILLNESS: , This is a 52-year-old native American-Indian man with hypertension, chronic intermittent bipedal edema, and recurrent leg venous ulcers, who was admitted on 01/27/09 for scheduled vascular surgery per Dr. X. I was consulted for nonhealing right ankle stasis ulcer.  There is a concern that the patient had a low-grade fever of 100.2 early this morning.  The patient otherwise feels well.  He was not even aware of the fever.  He does have some ankle pain, worse on the right than the left.  Old medical records were reviewed.  He has multiple hospitalizations for leg cellulitis.  Multiple wound cultures have repeatedly grown Pseudomonas, Enterococcus, and Stenotrophomonas in the past.  Klebsiella and Enterobacter have also grown in the few wound cultures at some point.  The patient has been following up at the wound center as an outpatient and was referred to Dr. X for definitive surgical management.,REVIEW OF SYSTEMS:,CONSTITUTIONAL:  No malaise.  Positive recent low-grade fevers.  No chills.,HEENT:  No acute change in visual acuity, no diplopia, no acute hearing disturbances, and no sinus congestion.  No sore throat.,CARDIAC:  No chest pain or cough.,GASTROINTESTINAL:  No nausea, vomiting or diarrhea.,All other systems were reviewed and were negative.,PAST MEDICAL HISTORY:  ,Hypertension, exploratory laparotomy in 2004 for abdominal obstruction, cholecystectomy in 2005, chronic intermittent bipedal edema, venous insufficiency, chronic recurrent stasis ulcers.,SOCIAL HISTORY: , The patient admits to heavy alcohol drinking in the past, quit several years ago.  He is also a former cigarette smoker, quit several years ago.,ALLERGIES:,  None known.,CURRENT MEDICATIONS:,  Primaxin, daptomycin, clonidine, furosemide, potassium chloride, lisinopril, metoprolol, ranitidine, Colace, amlodipine, zinc sulfate, Lortab p.r.n., multivitamins with minerals.,PHYSICAL EXAMINATION:,CONSTITUTIONAL/VITAL SIGNS:  Heart rate 73, respiratory rate 20, blood pressure 104/67, temperature 98.3, and oxygen saturation 92% on room air.,GENERAL APPEARANCE:  The patient is awake, alert, and not in cardiorespiratory distress.  Height 6 feet 1.5 inches, body weight 125.26 kilos.,EYES:  Pink conjunctivae, anicteric sclerae.  Pupils equal, brisk reaction to light.,EARS, NOSE, MOUTH AND THROAT:  Intact gross hearing.  Moist oral mucosa.  No oral lesions.,NECK:  No palpable neck masses.  Thyroid is not enlarged on inspection.,RESPIRATORY:  Regular inspiratory effort.  No crackles or wheezes.,CARDIOVASCULAR:  Regular cardiac rhythm.  No thrills or rubs.,GASTROINTESTINAL:  Normoactive bowel sounds.  Soft.  No guarding or rigidity.,LYMPHATIC:  No cervical lymphadenopathy.,MUSCULOSKELETAL:  Good range of motion of upper and lower extremities.,SKIN:  There is hyperpigmentation involving the distal calf of both legs.  There is an open wound on the right medial,malleolar area measuring 9 x 5cm with minimal serous drainage.  Periwound is hyperpigmented with a hint of erythema extending proximally to the medial aspect, distal third of the right lower leg.  There is warmth, but minimal tenderness on palpation of this area.  There is also a wound on the right lateral malleolar area measuring 4 x 3 cm, another open wound on the left medial malleolar area measuring 7 x 4 cm.  Wound edges are poorly defined.,PSYCHIATRIC:  Appropriate mood and affect, oriented x3.  Fair judgment and insight.,LABORATORY RESULTS: , White blood cell count from 01/28/09 is 5.8 with 64% neutrophils, H&H 11.3/33.8, and platelet count 176,000.  BUN and creatinine 9.2/0.52.  Albumin 3.6, AST 25, ALT 9, alk phos 87, and total bilirubin 0.6.  One wound culture from right leg wound culture from 01/27/09 noted with young growth.  Left leg wound culture from 01/27/09 also with young growth.,RADIOLOGY:,  Chest x-ray done on 01/28/09 showed chronic bibasilar subsegmental atelectasis likely related to elevated hemidiaphragm secondary to chronic ileus.  No absolute findings.,IMPRESSION:,1.  Fevers.,2.  Right leg/ankle cellulitis.,3.  Chronic recurrent bilateral ankle venous ulcers.,4.  Multiple previous wound cultures positive for Pseudomonas, Enterococcus, and Stenotrophomonas.,5.  Hypertension.,RECOMMENDATIONS:,1.  We have ordered 2 sets of blood cultures.,2.  Agree with daptomycin and Primaxin IV.,3.  Follow up result of wound cultures.,4.  I will order an MRI of the right ankle to check for underlying osteomyelitis.,Additional ID recommendations as appropriate upon followup.
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DESCRIPTION: Nonhealing right ankle stasis ulcer.  A 52-year-old native American-Indian man with hypertension, chronic intermittent bipedal edema, and recurrent leg venous ulcers was admitted for scheduled vascular surgery.

The situation involves a medical consultation for a patient with a nonhealing stasis ulcer and multiple underlying health issues, including hypertension and recurrent venous ulcers. There is a possibility of infection, as indicated by recurrent positive wound cultures and a recent low-grade fever. The potential complications, including cellulitis and the need to rule out osteomyelitis, make this a serious case. However, the patient is under medical supervision and scheduled for necessary diagnostic tests and treatments, which provides a level of control over the situation. The absence of severe symptoms like high fever or systemic infection at the moment suggests it is serious but not immediately life-threatening, hence not the highest stakes.


Medical Specialty: Surgery
Sample Name: Breast Mass Excision - 2

PREOPERATIVE DIAGNOSIS: , Breast mass, left.,POSTOPERATIVE DIAGNOSIS:,  Breast mass, left.,PROCEDURE:,  Excision of left breast mass.,OPERATION: , After obtaining an informed consent, the patient was taken to the operating room where he underwent general endotracheal anesthesia.  The time-out process was followed.  Preoperative antibiotic was given.  The patient was prepped and draped in the usual fashion.  The mass was identified adjacent to the left nipple.  It was freely mobile and it did not seem to hold the skin.  An elliptical skin incision was made over the mass and carried down in a pyramidal fashion towards the pectoral fascia.  The whole of specimen including the skin, the mass, and surrounding subcutaneous tissue and fascia were excised en bloc.  Hemostasis was achieved with the cautery.  The specimen was sent to Pathology and the tissues were closed in layers including a subcuticular suture of Monocryl.  A small pressure dressing was applied.,Estimated blood loss was minimal and the patient who tolerated the procedure very well was sent to recovery room in satisfactory condition.
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DESCRIPTION: Excision of left breast mass.  The mass was identified adjacent to the left nipple.  It was freely mobile and it did not seem to hold the skin.

surgery, breast mass excision, freely mobile, breast mass, endotracheal, fascia, specimen,

Breast mass excision, although a relatively common and generally low-risk surgical procedure, carries certain inherent risks associated with any surgery, such as infection, bleeding, and anesthesia complications. However, the description indicates that the procedure was completed successfully with minimal blood loss and the patient tolerated it well. The stakes are elevated due to the potential for the mass being malignant, which would require further treatment, but this is a typical concern in such procedures and is addressed by sending the specimen to pathology for analysis. Therefore, while important, the procedure isn't immediately life-threatening and has been performed successfully, making it lower stakes in a surgical context.


Medical Specialty: Neurosurgery
Sample Name: Anterior Cervical Discectomy & Arthrodesis

PREOPERATIVE DIAGNOSIS:,  Cervical myelopathy secondary to very large disc herniations at C4-C5 and C5-C6.,POSTOPERATIVE DIAGNOSIS: , Cervical myelopathy secondary to very large disc herniations at C4-C5 and C5-C6.,PROCEDURE PERFORMED:,1.  Anterior cervical discectomy, C4-C5 and C5-C6.,2.  Arthrodesis, C4-C5 and C5-C6.,3.  Partial corpectomy, C5.,4.  Machine bone allograft, C4-C5 and C5-C6.,5.  Placement of anterior cervical plate with a Zephyr C4 to C6.,6.  Fluoroscopic guidance.,7.  Microscopic dissection.,ANESTHESIA:,  General.,ESTIMATED BLOOD LOSS: , 60 mL.,COMPLICATIONS: , None.,INDICATIONS:,  This is a patient who presents with progressive weakness in the left upper extremity as well as imbalance.  He has also noted to have cord signal at the C4-C5 level secondary to a very large disc herniation that came behind the body at C5 as well and as well as a large disc herniation at C5-C6.  Risks and benefits of the surgery including bleeding, infection, neurologic deficit, nonunion, progressive spondylosis, and lack of improvement were all discussed.  He understood and wished to proceed.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating room and placed in the supine position.  Preoperative antibiotics were given.  The patient was placed in the supine position with all pressure points noted and well padded.  The patient was prepped and draped in standard fashion.  An incision was made approximately above the level of the cricoid.  Blunt dissection was used to expose the anterior portion of the spine with carotid moved laterally and trachea and esophagus moved medially.  We then placed needle into the disc spaces and was found to be at C5-C6.  Distracting pins were placed in the body of C4 and in to the body of C6.  The disc was then completely removed at C4-C5.  There was very significant compression of the cord.  This was carefully removed to avoid any type of pressure on the cord.  This was very severe and multiple free fragments were noted.  This was taken down to the level of ligamentum.  Both foramen were then also opened.  Other free fragments were also found behind the body of C5, part of the body of C5 was taken down to assure that all of these were removed.  The exact same procedure was done at C5-C6; however, if there were again free fragments noted, there was less not as severe compression at the C4-C5 area.  Again part of the body at C5 was removed to make sure that there was no additional constriction.  Both nerve roots were then widely decompressed.  Machine bone allograft was placed into the C4-C5 as well as C5-C6 and then a Zephyr plate was placed in the body of C4 and to the body of C6 with a metal pin placed into the body at C5.  Excellent purchase was obtained.  Fluoroscopy showed good placement and meticulous hemostasis was obtained.  Fascia was closed with 3-0 Vicryl, subcuticular 3-0 Dermabond for skin.  The patient tolerated the procedure well and went to recovery in good condition.
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DESCRIPTION: Anterior cervical discectomy, arthrodesis, partial corpectomy, Machine bone allograft, placement of anterior cervical plate with a Zephyr.
7.  Microscopic dissection.

neurosurgery, fluoroscopic guidance, microscopic dissectio, cervical plate, zephyr, corpectomy, arthrodesis, anterior cervical discectomy, machine bone allograft, cervical discectomy, bone allograft, disc herniations, anterior, cervical, discectomy,

The situation describes a surgical procedure for cervical myelopathy due to large disc herniations. The stakes are inherently high because neurosurgery involves operating on the spinal cord, which is critical for motor and sensory functions. Any errors during surgery can lead to serious, potentially life-altering complications such as paralysis or neurological deficits. Although the procedure described was completed without complications, the mere nature of the surgery and potential risks discussed make it high-stakes.


Medical Specialty: Gastroenterology
Sample Name: Colonoscopy & Polypectomy - 3

PREOPERATIVE DIAGNOSIS:,  Alternating hard and soft stools.,POSTOPERATIVE DIAGNOSIS:,Sigmoid diverticulosis.,Sessile polyp of the sigmoid colon.,Pedunculated polyp of the sigmoid colon.,PROCEDURE: , Total colonoscopy with biopsy and snare polypectomy.,PREP:,  4/4.,DIFFICULTY:,  1/4.,PREMEDICATION AND SEDATION: , Fentanyl 100, midazolam 5.,INDICATION FOR PROCEDURE:,  A 64-year-old male who has developed alternating hard and soft stools.  He has one bowel movement a day.,FINDINGS: , There is extensive sigmoid diverticulosis, without evidence of inflammation or bleeding.  There was a small, sessile polyp in the sigmoid colon, and a larger pedunculated polyp in the sigmoid colon, both appeared adenomatous.,DESCRIPTION OF PROCEDURE: , Preoperative counseling, including an explicit discussion of the risk and treatment of perforation was provided.  Preoperative physical examination was performed.  Informed consent was obtained.  The patient was placed in the left lateral decubitus position.  Premedications were given slowly by intravenous push.  Rectal examination was performed, which was normal.  The scope was introduced and passed with minimal difficulty to the cecum.  This was verified anatomically and video photographs were taken of the ileocecal valve and appendiceal orifice.  The scope was slowly withdrawn, the mucosa carefully visualized.  It was normal in its entirety until reaching the sigmoid colon.  Sigmoid colon had extensive diverticular disease, small-mouth, without inflammation or bleeding.  In addition, there was a small sessile polyp, which was cold biopsied and recovered, and approximately an 8 mm pedunculated polyp.  A snare was placed on the stalk of the polyp and divided with electrocautery.  The polyp was recovered and sent for pathologic examination.  Examination of the stalk showed good hemostasis.  The scope was slowly withdrawn and the remainder of the examination was normal.,ASSESSMENT: , Diverticular disease.  A diverticular disease handout was given to the patient's wife and a high fiber diet was recommended.  In addition, 2 polyps, one of which is assuredly an adenoma.  Patient needs a repeat colonoscopy in 3 years.
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DESCRIPTION: Total colonoscopy with biopsy and snare polypectomy.

gastroenterology, total colonoscopy with biopsy, colonoscopy with biopsy, total colonoscopy, snare polypectomy, sigmoid diverticulosis, sessile polyp, pedunculated polyp, diverticular disease, sigmoid colon, colonoscopy, polypectomy, biopsy, diverticulosis, inflammation, adenomatous, sessile, sigmoid,

The situation involves a medical procedure, specifically a colonoscopy with biopsy and snare polypectomy, which is a common but serious medical examination. The stakes are elevated due to the nature of the procedure, the involvement of potential adenomatous polyps, and the patient's condition of sigmoid diverticulosis. These factors elevate potential risks, such as perforation during the procedure, but the procedure itself is routine for gastroenterologists. The preoperative and postoperative diagnoses inform the future care plan, but they do not suggest an immediate, life-threatening condition, keeping the stakes moderate rather than extremely high.


Medical Specialty: Radiology
Sample Name: CT Abdomen & Pelvis - 1

EXAM: , CT Abdomen and Pelvis with contrast ,REASON FOR EXAM:, Nausea, vomiting, diarrhea for one day.  Fever.  Right upper quadrant pain for one day.  ,COMPARISON: , None. ,TECHNIQUE:,  CT of the abdomen and pelvis performed without and with approximately 54 ml Isovue 300 contrast enhancement.  ,CT ABDOMEN: , Lung bases are clear.  The liver, gallbladder, spleen, pancreas, and bilateral adrenal/kidneys are unremarkable.  The aorta is normal in caliber.  There is no retroperitoneal lymphadenopathy.  ,CT PELVIS: , The appendix is visualized along its length and is diffusely unremarkable with no surrounding inflammatory change.  Per CT, the colon and small bowel are unremarkable.  The bladder is distended.  No free fluid/air.  Visualized osseous structures demonstrate no definite evidence for acute fracture, malalignment, or dislocation.,IMPRESSION:,1.  Unremarkable exam; specifically no evidence for acute appendicitis. ,2.  No acute nephro-/ureterolithiasis. ,3.  No secondary evidence for acute cholecystitis.,Results were communicated to the ER at the time of dictation.
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DESCRIPTION: CT Abdomen and Pelvis with contrast

CT Abdomen and Pelvis with contrast

radiology, liver, gallbladder, spleen, pancreas, adrenal, kidneys, lymphadenopathy, abdomen and pelvis, contrast, ct

The situation involves the interpretation of a CT scan for an individual presenting with symptoms that could potentially indicate serious conditions, such as appendicitis or cholecystitis. However, the results show no acute findings, indicating a non-critical outcome. The radiologist's report indicates that the scan was unremarkable, which means that the immediate risk to the patient is low. The results were quickly communicated to the ER, underscoring the importance of timely results in a healthcare setting, but without further acute findings, the immediate stakes are not high.


Medical Specialty: Consult - History and Phy.
Sample Name: GI Consultation - 1

PROBLEM:  ,Rectal bleeding, positive celiac sprue panel.,HISTORY:  ,The patient is a 19-year-old Irish-Greek female who ever since elementary school has noted diarrhea, constipation, cramping, nausea, vomiting, bloating, belching, abdominal discomfort, change in bowel habits.  She noted that her symptoms were getting increasingly worse and so she went for evaluation and was finally tested for celiac sprue and found to have a positive tissue transglutaminase as well as antiendomysial antibody.  She has been on a gluten-free diet for approximately one week now and her symptoms are remarkably improved.  She actually has none of these symptoms since starting her gluten-free diet.  She has noted intermittent rectal bleeding with constipation, on the toilet tissue.  She feels remarkably better after starting a gluten-free diet.,ALLERGIES: , No known drug allergies.,OPERATIONS: , She is status post a tonsillectomy as well as ear tubes.,ILLNESSES: , Questionable kidney stone.,MEDICATIONS: , None.,HABITS: , No tobacco.  No ethanol.,SOCIAL HISTORY: , She lives by herself.  She currently works in a dental office.,FAMILY HISTORY: , Notable for a mother who is in good health, a father who has joint problems and questionable celiac disease as well.  She has two sisters and one brother.  One sister interestingly has inflammatory arthritis.,REVIEW OF SYSTEMS:  ,Notable for fever, fatigue, blurred vision, rash and itching; her GI symptoms that were discussed in the HPI are actually resolved in that she started the gluten-free diet.  She also notes headaches, anxiety, heat and cold intolerance, excessive thirst and urination.  Please see symptoms summary sheet dated April 18, 2005.,PHYSICAL EXAMINATION:  , GENERAL:  She is a well-developed pleasant 19 female.  She has a blood pressure of 120/80, a pulse of 70, she weighs 170 pounds.  She has anicteric sclerae.  Pink conjunctivae.  PERRLA.  ENT:  MMM.  NECK:  Supple.  LUNGS: Clear to auscultation.
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DESCRIPTION: GI Consultation due to rectal bleeding, positive celiac sprue panel

consult - history and phy., bleeding, abdominal discomfort, belching, bloating, bowel, celiac sprue, change in bowel habits, constipation, cramping, diarrhea, gluten-free, nausea, rectal, vomiting, inflammatory arthritis, rectal bleeding, gi, inflammatory, sprue, celiac, gluten, diet,

The situation involves a consultation for a 19-year-old female with rectal bleeding and a positive test for celiac sprue, which she is managing with a gluten-free diet. The rectal bleeding could be indicative of a serious health issue if not properly evaluated, though her other symptoms have significantly improved with diet changes. Celiac disease and its management are crucial, especially with the addition of new symptoms like rectal bleeding. Proper evaluation is needed to ensure there are no other underlying issues, such as hemorrhoids or other gastrointestinal problems, but it doesn't necessarily suggest an immediate life-threatening condition.


Medical Specialty: Surgery
Sample Name: Radical Vulvectomy

PREOPERATIVE DIAGNOSIS: , Clinical stage III squamous cell carcinoma of the vulva.,POSTOPERATIVE DIAGNOSIS: , Clinical stage III squamous cell carcinoma of the vulva.,OPERATION PERFORMED:,  Radical vulvectomy (complete), bilateral inguinal lymphadenectomy (superficial and deep).,ANESTHESIA: , General, endotracheal tube.,SPECIMENS: , Radical vulvectomy, right and left superficial and deep inguinal lymph nodes. ,INDICATIONS FOR PROCEDURE: , The patient recently presented with a new vaginal nodule. Biopsy was obtained and revealed squamous carcinoma.  The lesion extended slightly above the hymeneal ring and because of vaginal involvement was classified as a T3/Nx/Mx on clinical examination.  Of note, past history is significant for pelvic radiation for cervical cancer many years previously.,FINDINGS: , The examination under anesthesia revealed a 1.5 cm nodule of disease extending slightly above the hymeneal ring.  There was no palpable lymphadenopathy in either inguinal node region.  There were no other nodules, ulcerations, or other lesions.  At the completion of the procedure there was no clinical evidence of residual disease.,PROCEDURE:,  The patient was brought to the Operating Room with an IV in place.  She was placed in the low anterior lithotomy position after adequate anesthesia had been induced.  Examination under anesthesia was performed with findings as noted, after which she was prepped and draped.  The femoral triangles were marked and a 10 cm skin incision was made parallel to the inguinal ligament approximately 3 cm below the ligament.  Camper's fascia was divided and skin flaps were elevated with sharp dissection and ligation of vessels where necessary.  The lymph node bundles were mobilized by incising the loose areolar tissue attachments to the fascia of the rectus abdominis.  The fascia around the sartorius muscle was divided and the specimen was reflected from lateral to medial.  The cribriform fascia was isolated and dissected with preservation of the femoral nerve.  The femoral sheath containing artery and vein was opened and vessels were stripped of their lymphatic attachments.  The medial lymph node bundle was isolated, and Cloquet's node was clamped, divided, and ligated bilaterally.  The saphenous vessels were identified and preserved bilaterally.  The inferior margin of the specimen was ligated, divided, and removed.  Inguinal node sites were irrigated and excellent hemostasis was noted.  Jackson-Pratt drains were placed and Camper's fascia was approximated with simple interrupted stitches.  The skin was closed with running subcuticular stitches using 4-0 Monocryl suture.,Attention was turned to the radical vulvectomy specimen.  A marking pen was used to outline the margins of resection allowing 15-20 mm of margin on the inferior, lateral, and anterior margins.  The medial margin extended into the vagina and was approximately 5-8 mm.  The skin was incised and underlying adipose tissue was divided with electrocautery.  Vascular bundles were isolated, divided, and ligated.  After removal of the specimen, additional margin was obtained from the right vaginal side wall adjacent to the tumor site.  Margins were submitted on the right posterior, middle, and anterior vaginal side walls.  After removal of the vaginal margins, the perineum was irrigated with four liters of normal saline and deep tissues were approximated with simple interrupted stitches of 2-0 Vicryl suture.  The skin was closed with interrupted horizontal mattress stitches using 3-0 Vicryl suture.  The final sponge, needle, and instrument counts were correct at the completion of the procedure.  The patient was then awakened from her anesthetic and taken to the Post Anesthesia Care Unit in stable condition.
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DESCRIPTION: Radical vulvectomy (complete), bilateral inguinal lymphadenectomy (superficial and deep).

surgery, squamous cell carcinoma, vulvectomy, radical vulvectomy, bilateral inguinal lymphadenectomy, hymeneal ring, camper's fascia, carcinoma of the vulva, inguinal lymphadenectomy, lymph nodes, inguinal, vulva, squamous, carcinoma, radical, lymphadenectomy, fascia, vaginal, nodes

This report describes a complex surgical procedure for a patient with advanced-stage squamous cell carcinoma of the vulva. The stakes are high due to the complexity and invasive nature of the operation, which involves handling critical anatomical structures and ensuring cancerous tissues are effectively removed to prevent recurrence. Postoperative recovery and long-term outcomes are significant concerns. The patient's past medical history, including previous pelvic radiation, adds to the complexity and risk. Therefore, I consider this situation as high-stakes, requiring precise surgical skills and careful postoperative management.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Echocardiogram - 3

REASON FOR EXAM:,1.  Angina.,2.  Coronary artery disease.,INTERPRETATION:  ,This is a technically acceptable study.,DIMENSIONS:  ,Anterior septal wall 1.2, posterior wall 1.2, left ventricular end diastolic 6.0, end systolic 4.7.  The left atrium is 3.9.,FINDINGS:  ,  Left atrium was mildly to moderately dilated.  No masses or thrombi were seen.  The left ventricle was mildly dilated with mainly global hypokinesis, more prominent in the inferior septum and inferoposterior wall.  The EF was moderately reduced with estimated EF of 40% with near normal thickening.  The right atrium was mildly dilated.  The right ventricle was normal in size.,Mitral valve showed to be structurally normal with no prolapse or vegetation.  There was mild mitral regurgitation on color flow interrogation.  The mitral inflow pattern was consistent with pseudonormalization or grade 2 diastolic dysfunction.  The aortic valve appeared to be structurally normal.  Normal peak velocity.  No significant AI.  Pulmonic valve showed mild PI.  Tricuspid valve showed mild tricuspid regurgitation.  Based on which, the right ventricular systolic pressure was estimated to be mildly elevated at 40 to 45 mmHg.  Anterior septum appeared to be intact.  No pericardial effusion was seen.,CONCLUSION:,1.  Mild biatrial enlargement.,2.  Normal thickening of the left ventricle with mildly dilated ventricle and EF of 40%.,3.  Mild mitral regurgitation.,4.  Diastolic dysfunction grade 2.,5.  Mild pulmonary hypertension.
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DESCRIPTION: Echocardiographic Examination Report.   Angina and coronary artery disease.  Mild biatrial enlargement, normal thickening of the left ventricle with mildly dilated ventricle and EF of 40%, mild mitral regurgitation, diastolic dysfunction grade 2, mild pulmonary hypertension.

cardiovascular / pulmonary, angina, coronary artery disease, septal, ventricular, diastolic, systolic, pulmonary hypertension, mitral regurgitation, septum, tricuspid, thickening, dysfunction, wall, ef, regurgitation, atrium, valve, dilated, mitral, ventricle, mildly,

The echocardiogram results indicate multiple cardiovascular issues, including coronary artery disease, mild biatrial enlargement, mild mitral regurgitation, diastolic dysfunction, and mild pulmonary hypertension, accompanied by a moderately reduced ejection fraction of 40%. These findings suggest a patient with significant heart function impairment, which could lead to serious health complications if not properly managed. The presence of coronary artery disease adds to the complexity and potential risk of acute cardiac events. This makes the situation reasonably high-stakes as it involves maintaining a balance between managing current symptoms and preventing further complications impacting the patient's health.


Medical Specialty: Surgery
Sample Name: I&D - ORIF Wound

TITLE OF OPERATION:,1.  Irrigation and debridement of postoperative wound infection (CPT code 10180).,2.  Removal of foreign body, deep (CPT code 28192).,3.  Placement of vacuum-assisted closure device, less than 50 centimeter squared (CPT code 97605).,PREOP DIAGNOSIS: , Postoperative wound infection, complicated (ICD-9 code 998.59).,POSTOP DIAGNOSIS: , Postoperative wound infection, complicated (ICD-9 code 998.59).,PROCEDURE DETAIL:  ,The patient is a 59-year-old gentleman who is status post open reduction and internal fixation of bilateral calcanei.  He was admitted for a left wound breakdown with drainage.  He underwent an irrigation and debridement with VAC placement 72 hours prior to this operative visit.  It was decided to bring him back for a repeat irrigation and debridement and VAC change prior to Plastics doing a local flap.  The risks of surgery were discussed in detail including, but not limited to infection, bleeding, injuries to nerves and vital structures, need for reoperation, pain or stiffness, arthritis, fracture, the risk of anesthesia.  The patient understood these risks and wished to proceed.  The patient was admitted, and the operative site was marked.,The patient was brought to the operating room and given general anesthetic.  He was placed in the right lateral decubitus, and all bony prominences were well padded.  An axillary roll was placed.  A well-padded thigh tourniquet was placed on the left leg.  The patient then received antibiotics on the floor prior to coming down to the operating room which satisfied the preoperative requirement.  Left leg was then prepped and draped in usual sterile fashion.  The previous five antibiotic spacer beads were removed without difficulty.  The wound was then rongeured and curetted, and all bone was cleaned down to healthy bleeding bone.  The wound actually looked quite good with evidence of purulence or drainage.  Skin edges appeared to be viable.  Hardware all looked to be intact.  At this point, the wound was irrigated with 9 liters of bibiotic solution.  A VAC sponge was then placed over the wound, and the patient's leg was placed into a posterior splint.  The patient was awakened and then taken to recovery in good condition.,Dr. X was present for the timeouts and for all critical portions of the procedure.  He was immediately available for any questions during the case.,PLAN:,1.  A CAM walker boots.,2.  A VAC change on Sunday by the nurse.,3.  A flap per Plastic Surgery.
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DESCRIPTION: Postoperative wound infection, complicated.  Irrigation and debridement of postoperative wound infection.  Removal of foreign body.  Placement of vacuum-assisted closure.device.

surgery, irrigation and debridement, removal of foreign body, vacuum-assisted closure device, foreign body, postoperative wound, wound infection, infection, wound, orif, debridement, vacuum,

The situation involves a surgical procedure related to a postoperative wound infection, which can have serious consequences if not treated properly. The procedure includes irrigation and debridement, removal of foreign bodies, and the use of a vacuum-assisted closure device, highlighting its importance in preventing further complications like severe infection or compromised healing. Additionally, the risks discussed (infection, bleeding, nerve injuries, etc.) underline the stakes associated with surgical interventions. The recurrence of the situation and the need for a well-coordinated follow-up plan with plastics for a flap further emphasize the potential complications that can arise if not managed correctly, indicating the high-stakes nature of the medical context.


Medical Specialty: Gastroenterology
Sample Name: Paracentesis - Ultrasound-Guided

EXAM:,  Ultrasound-guided paracentesis,HISTORY: , Ascites.,TECHNIQUE AND FINDINGS:  ,Informed consent was obtained from the patient after the risks and benefits of the procedure were thoroughly explained.  Ultrasound demonstrates free fluid in the abdomen.  The area of interest was localized with ultrasonography.  The region was sterilely prepped and draped in the usual manner.  Local anesthetic was administered.  A 5-French Yueh catheter needle combination was taken.  Upon crossing into the peritoneal space and aspiration of fluid, the catheter was advanced out over the needle.  A total of approximately 5500 mL of serous fluid was obtained.  The catheter was then removed.  The patient tolerated the procedure well with no immediate postprocedure complications.,IMPRESSION: , Ultrasound-guided paracentesis as above.
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DESCRIPTION: Ultrasound-Guided Paracentesis for Ascites

gastroenterology, yueh catheter, aspiration of fluid, ultrasound guided paracentesis, ultrasound guided, needle, catheter, paracentesis, ultrasound, ascites

Paracentesis is a procedure to remove fluid from the abdominal cavity, particularly used for patients with ascites. While common in practice, it involves risks such as infection, bleeding, or damage to internal organs. These risks require informed consent and careful execution, especially given the significant amount of fluid involved in this case (5500 mL). Although the patient tolerated the procedure well in this scenario, the potential for serious complications adds to the stakes.


Medical Specialty: Nephrology
Sample Name: Consult - Hydronephrosis

CHIEF COMPLAINT:,  Right hydronephrosis.,HISTORY OF PRESENT ILLNESS: , The patient is a 56-year-old female who has a history of uterine cancer, breast cancer, mesothelioma.  She is scheduled to undergo mastectomy in two weeks.  In September 1999, she was diagnosed with right breast cancer and underwent lumpectomy and axillary node dissection and radiation.  Again, she is scheduled for mastectomy in two weeks.  She underwent a recent PET scan for Dr. X, which revealed marked hydronephrosis on the right possibly related to right UPJ obstruction and there is probably a small nonobstructing stone in the upper pole of the right kidney.  There was no dilation of the right ureter noted.  Urinalysis today is microscopically negative.,PAST MEDICAL HISTORY: , Uterine cancer, mesothelioma, breast cancer, diabetes, hypertension.,PAST SURGICAL HISTORY: , Lumpectomy, hysterectomy.,MEDICATIONS:,  Diovan HCT 80/12.5 mg daily, metformin 500 mg daily.,ALLERGIES:,  None.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY:,  She is retired.  Does not smoke or drink.,REVIEW OF SYSTEMS:,  I have reviewed his review of systems sheet and it is on the chart.,PHYSICAL EXAMINATION:,  Please see the physical exam sheet I completed.  Abdomen is soft, nontender, nondistended, no palpable masses, no CVA tenderness.,IMPRESSION AND PLAN: , Marked right hydronephrosis without hydruria.  She believes she had a CT scan of the abdomen and pelvis at Hospital in 2005.  I will try to obtain the report to see if the right kidney was evaluated at that time.  She will need evaluation with an IVP and renal scan to determine the point of obstruction and renal function of the right kidney.  She is quite anxious about her upcoming surgery and would like to delay any evaluation of this until the surgery is completed.  She will call us back to schedule the x-rays.  She understands the great importance and getting back in touch with us to schedule these x-rays due to the possibility that it may be somehow related to the cancer.  There is also a question of a stone present in the kidney.  She voiced a complete understanding of that and will call us after she recovers from her surgery to schedule these tests.
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DESCRIPTION: Marked right hydronephrosis without hydruria.

nephrology, hydruria, hydronephrosis, review of systems, uterine cancer, breast cancer, mesothelioma, mastectomy, kidney, cancer,

The patient has a complex medical history, including uterine cancer, breast cancer, and mesothelioma, with an upcoming mastectomy scheduled. The recent finding of marked right hydronephrosis could be significant, as it may affect kidney function and possibly relate to her cancer history. Although the patient is opting to delay evaluation due to her imminent surgery, the situation involves potential risks, such as loss of kidney function or the obstruction worsening. These factors contribute to a high-stakes scenario due to the implications on the patient's overall health and the potential need for urgent intervention if symptoms worsen.


Medical Specialty: Orthopedic
Sample Name: Carpal Tunnel Release - 6

PREOPERATIVE DIAGNOSIS: , Left carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS:,  Left carpal tunnel syndrome.,OPERATIVE PROCEDURE PERFORMED:,  Left carpal tunnel release.,FINDINGS:,  Showed severe compression of the median nerve on the left at the wrist.,SPECIMENS:  ,None.,FLUIDS:,  500 mL of crystalloids.,URINE OUTPUT:,  No Foley catheter.,COMPLICATIONS: , None.,ANESTHESIA: , General through a laryngeal mask.,ESTIMATED BLOOD LOSS: , None.,CONDITION: , Resuscitated with stable vital signs.,INDICATION FOR THE OPERATION: , This is a case of a very pleasant 65-year-old forensic pathologist who I previously had performed initially a discectomy and removal of infection at 6-7, followed by anterior cervical discectomy with anterior interbody fusion at C5-6 and C6-7 with spinal instrumentation.  At the time of initial consultation, the patient was also found to have bilateral carpal tunnel and for which we are addressing the left side now.  Operation, expected outcome, risks, and benefits were discussed with him for most of the risk would be that of infection because of the patient's diabetes and a previous history of infection in the form of pneumonia.  There is also the possibility of bleeding as well as the possibility of injury to the median nerve on dissection.  He understood this risk and agreed to have the procedure performed.,DESCRIPTION OF THE PROCEDURE: , The patient was brought to the operating room, awake, alert, not in any form of distress.  After smooth induction of anesthesia and placement of a laryngeal mask, he remained supine on the operating table.  The left upper extremity was then prepped with Betadine soap and antiseptic solution.  After sterile drapes were laid out, an incision was made following inflation of blood pressure cuff to 250 mmHg.  Clamp time approximately 30 minutes.  An incision was then made right in the mid palm area between the thenar and hypothenar eminence.  Meticulous hemostasis of any bleeders were done.  The fat was identified.  The palmar aponeurosis was identified and cut and this was traced down to the wrist.  There was severe compression of the median nerve.  Additional removal of the aponeurosis was performed to allow for further decompression.  After this was all completed, the area was irrigated with saline and bacitracin solution and closed as a single layer using Prolene 4-0 as interrupted vertical mattress stitches.  Dressing was applied.  The patient was brought to the recovery.
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DESCRIPTION: Left carpal tunnel release.  Left carpal tunnel syndrome.  Severe compression of the median nerve on the left at the wrist.

orthopedic, compression, wrist, carpal tunnel release, carpal tunnel syndrome, median nerve, tunnel, carpal,

Carpal tunnel release surgery is a common orthopedic procedure performed to alleviate symptoms associated with carpal tunnel syndrome, such as pain and numbness due to compression of the median nerve. While surgical procedures inherently have some level of risk, including the potential for infection and nerve damage, the overall stakes of a carpal tunnel release are not as high as in more complex surgeries that involve critical systems or have a higher likelihood of life-threatening complications. The patient is at a slightly higher risk due to diabetes and a prior history of infections, but this particular scenario described a smooth procedure with no complications, stable vital signs, and successful completion of the decompression. The stakes are moderated by these factors, making it a routine but important medical procedure.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Coronary Angiography

REASON FOR EXAM: , Dynamic ST-T changes with angina.,PROCEDURE:,1.  Selective coronary angiography.,2.  Left heart catheterization with hemodynamics.,3.  LV gram with power injection.,4.  Right femoral artery angiogram.,5.  Closure of the right femoral artery using 6-French AngioSeal.,Procedure explained to the patient, with risks and benefits.  The patient agreed and signed the consent form.,The patient received a total of 2 mg of Versed and 25 mcg of fentanyl for conscious sedation.  The patient was draped and dressed in the usual sterile fashion.  The right groin area infiltrated with lidocaine solution.  Access to the right femoral artery was successful, okayed with one attempt with anterior wall stick.  Over a J-wire, 6-French sheath was introduced using modified Seldinger technique.,Over the J-wire, a JL4 catheter was passed over the aortic arch.  The wire was removed.  Catheter was engaged into the left main.  Multiple pictures with RAO caudal, AP cranial, LAO cranial, shallow RAO, and LAO caudal views were all obtained.  Catheter disengaged and exchanged over J-wire into a JR4 catheter, the wire was removed.  Catheter with counter-clock was rotating to the RCA one shot with LAO, position was obtained.  The cath disengaged and exchanged over J-wire into a pigtail catheter.  Pigtail catheter across the aortic valve.  Hemodynamics obtained.  LV gram with power injection of 36 mL of contrast was obtained.,The LV gram assessed followed by pullback hemodynamics.,The catheter exchanged out and the right femoral artery angiogram completed to the end followed by the removal of the sheath and deployment of 6-French AngioSeal with no hematoma.  The patient tolerated the procedure well with no immediate postprocedure complication.,HEMODYNAMICS:  ,The aortic pressure was 117/61 with a mean pressure of 83.  The left ventricular pressure was 119/9 to 19 with left ventricular end-diastolic pressure of 17 to 19 mmHg.  The pullback across the aortic valve reveals zero gradient.,ANATOMY:  ,The left main showed minimal calcification as well as the proximal LAD.  No stenosis in the left main seen, the left main bifurcates in to the LAD and left circumflex.,The LAD was a large and a long vessel that wraps around the apex showed no focal stenosis or significant atheromatous plaque and the flow was TIMI 3 flow in the LAD.  The LAD gave off two early diagonal branches.  The second was the largest of the two and showed minimal lumen irregularities, but no focal stenosis.,Left circumflex was a dominant system supplying three obtuse marginal branches and distally supplying the PDA.  The left circumflex was large and patent, 6.0 mm in diameter.  All three obtuse marginal branches appeared to be with no significant stenosis.,The obtuse marginal branch, the third OM3 showed at the origin about 30 to 40% minimal narrowing, but no significant stenosis.  The PDA was wide, patent, with no focal stenosis.,The RCA was a small nondominant system with no focal stenosis and supplying the RV marginal.,LV gram showed that the LV EF is preserved with EF of 60%.  No mitral regurgitation identified.,IMPRESSION:,1.  Patent coronary arteries with normal left anterior descending, left circumflex, and dominant left circumflex system.,2.  Nondominant right, which is free of atheromatous plaque.,3.  Minimal plaque in the diagonal branch II, and the obtuse,marginal branch III, with no focal stenosis.,4.  Normal left ventricular function.,5.  Evaluation for noncardiac chest pain would be recommended.
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DESCRIPTION: Selective coronary angiography, left heart catheterization with hemodynamics, LV gram with power injection, right femoral artery angiogram, closure of the right femoral artery using 6-French AngioSeal.

This procedure, coronary angiography, is critical for diagnosing and assessing the coronary arteries' status and cardiac function in patients experiencing symptoms like angina. The stakes are heightened due to the invasive nature of the procedure, the risks associated with angiography (e.g., bleeding, arterial damage), and the potential for findings to significantly impact treatment decisions. Furthermore, any errors in assessment or complications can have serious consequences for patient health. Thus, the stakes are relatively high, impacting both the immediate safety of the patient and the future management of their cardiovascular health.


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

Medical Specialty: Obstetrics / Gynecology
Sample Name: Radical Vulvectomy

PREOPERATIVE DIAGNOSIS: , Clinical stage III squamous cell carcinoma of the vulva.,POSTOPERATIVE DIAGNOSIS: , Clinical stage III squamous cell carcinoma of the vulva.,OPERATION PERFORMED:,  Radical vulvectomy (complete), bilateral inguinal lymphadenectomy (superficial and deep).,ANESTHESIA: , General, endotracheal tube.,SPECIMENS: , Radical vulvectomy, right and left superficial and deep inguinal lymph nodes. ,INDICATIONS FOR PROCEDURE: , The patient recently presented with a new vaginal nodule. Biopsy was obtained and revealed squamous carcinoma.  The lesion extended slightly above the hymeneal ring and because of vaginal involvement was classified as a T3/Nx/Mx on clinical examination.  Of note, past history is significant for pelvic radiation for cervical cancer many years previously.,FINDINGS: , The examination under anesthesia revealed a 1.5 cm nodule of disease extending slightly above the hymeneal ring.  There was no palpable lymphadenopathy in either inguinal node region.  There were no other nodules, ulcerations, or other lesions.  At the completion of the procedure there was no clinical evidence of residual disease.,PROCEDURE:,  The patient was brought to the Operating Room with an IV in place.  She was placed in the low anterior lithotomy position after adequate anesthesia had been induced.  Examination under anesthesia was performed with findings as noted, after which she was prepped and draped.  The femoral triangles were marked and a 10 cm skin incision was made parallel to the inguinal ligament approximately 3 cm below the ligament.  Camper's fascia was divided and skin flaps were elevated with sharp dissection and ligation of vessels where necessary.  The lymph node bundles were mobilized by incising the loose areolar tissue attachments to the fascia of the rectus abdominis.  The fascia around the sartorius muscle was divided and the specimen was reflected from lateral to medial.  The cribriform fascia was isolated and dissected with preservation of the femoral nerve.  The femoral sheath containing artery and vein was opened and vessels were stripped of their lymphatic attachments.  The medial lymph node bundle was isolated, and Cloquet's node was clamped, divided, and ligated bilaterally.  The saphenous vessels were identified and preserved bilaterally.  The inferior margin of the specimen was ligated, divided, and removed.  Inguinal node sites were irrigated and excellent hemostasis was noted.  Jackson-Pratt drains were placed and Camper's fascia was approximated with simple interrupted stitches.  The skin was closed with running subcuticular stitches using 4-0 Monocryl suture.,Attention was turned to the radical vulvectomy specimen.  A marking pen was used to outline the margins of resection allowing 15-20 mm of margin on the inferior, lateral, and anterior margins.  The medial margin extended into the vagina and was approximately 5-8 mm.  The skin was incised and underlying adipose tissue was divided with electrocautery.  Vascular bundles were isolated, divided, and ligated.  After removal of the specimen, additional margin was obtained from the right vaginal side wall adjacent to the tumor site.  Margins were submitted on the right posterior, middle, and anterior vaginal side walls.  After removal of the vaginal margins, the perineum was irrigated with four liters of normal saline and deep tissues were approximated with simple interrupted stitches of 2-0 Vicryl suture.  The skin was closed with interrupted horizontal mattress stitches using 3-0 Vicryl suture.  The final sponge, needle, and instrument counts were correct at the completion of the procedure.  The patient was then awakened from her anesthetic and taken to the Post Anesthesia Care Unit in stable condition.
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DESCRIPTION: Radical vulvectomy (complete), bilateral inguinal lymphadenectomy (superficial and deep).

obstetrics / gynecology, squamous cell carcinoma, vulvectomy, radical vulvectomy, bilateral inguinal lymphadenectomy, hymeneal ring, camper's fascia, carcinoma of the vulva, inguinal lymphadenectomy, lymph nodes, inguinal, vulva, squamous, carcinoma, radical, lymphadenectomy, fascia, vaginal, nodes

The situation involves a radical vulvectomy and bilateral inguinal lymphadenectomy for a patient with clinical stage III squamous cell carcinoma of the vulva. This surgery is high-stakes due to the nature of the cancer, the complexity of the procedure, and the potential risks involved, such as damage to nearby structures, managing hemostasis, and ensuring complete removal of cancerous tissue. Additionally, the patient's significant medical history, including prior pelvic radiation for cervical cancer, adds to the complexity and stakes of the situation. The surgery aims to remove the cancerous tissue effectively to prevent further spread, which is critical for the patient's prognosis.


Medical Specialty: Orthopedic
Sample Name: MRI of Lumbar Spine w/o Contrast

EXAM: , MRI of lumbar spine without contrast.,HISTORY:,  A 24-year-old female with chronic back pain.,TECHNIQUE: , Noncontrast axial and sagittal images were acquired through the lumbar spine in varying degrees of fat and water weighting.,FINDINGS: , The visualized cord is normal in signal intensity and morphology with conus terminating in proper position.  Visualized osseous structures are normal in marrow signal intensity and morphology without evidence for fracture/contusion, compression deformity, or marrow replacement process.  There are no paraspinal masses.,Disc heights, signal, and vertebral body heights are maintained throughout the lumbar spine.,L5-S1:  Central canal, neural foramina are patent.,L4-L5:  Central canal, neural foramina are patent.,L3-L4:  Central canal, neural foramen is patent.,L2-L3:  Central canal, neural foramina are patent.,L1-L2:  Central canal, neural foramina are patent.,The visualized abdominal aorta is normal in caliber.  Incidental note has been made of multiple left-sided ovarian, probable physiologic follicular cysts.,IMPRESSION: , No acute disease in the lumbar spine.
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DESCRIPTION: MRI of lumbar spine without contrast to evaluate chronic back pain.

orthopedic, mri, central canal, noncontrast, abdominal aorta, axial, back pain, contrast, follicular cysts, images, lumbar spine, morphology, neural foramina, sagittal, signal intensity, without contrast, mri of lumbar spine, mri of lumbar, lumbar, foramina, neural, patent, spine

The situation involves interpreting an MRI scan for chronic back pain in a young adult. While important for diagnosis and patient care, the findings indicate no acute issues, suggesting there is no immediate high-risk condition present. Since this is a diagnostic imaging scenario without any detected acute abnormalities or immediate need for intervention, it is lower on the stakes spectrum.


Medical Specialty: Discharge Summary
Sample Name: Chest Pain & Respiratory Insufficiency

We discovered new T-wave abnormalities on her EKG.  There was of course a four-vessel bypass surgery in 2001.  We did a coronary angiogram.  This demonstrated patent vein grafts and patent internal mammary vessel and so there was no obvious new disease.,She may continue in the future to have angina and she will have nitroglycerin available for that if needed.,Her blood pressure has been elevated and so instead of metoprolol, we have started her on Coreg 6.25 mg b.i.d.  This should be increased up to 25 mg b.i.d. as preferred antihypertensive in this lady's case.  She also is on an ACE inhibitor.,So her discharge meds are as follows:,1.  Coreg 6.25 mg b.i.d.,2.  Simvastatin 40 mg nightly.,3.  Lisinopril 5 mg b.i.d.,4.  Protonix 40 mg a.m.,5.  Aspirin 160 mg a day.,6.  Lasix 20 mg b.i.d.,7.  Spiriva puff daily.,8.  Albuterol p.r.n. q.i.d.,9.  Advair 500/50 puff b.i.d.,10.  Xopenex q.i.d. and p.r.n.,I will see her in a month to six weeks.  She is to follow up with Dr. X before that.
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DESCRIPTION: A lady was admitted to the hospital with chest pain and respiratory insufficiency.  She has chronic lung disease with bronchospastic angina.

discharge summary, chest pain, respiratory insufficiency, chronic lung disease, bronchospastic angina, insufficiency, chest, angina, respiratory, bronchospastic

This situation involves the discharge summary of a patient with a history of heart and lung issues, who was admitted due to chest pain and respiratory insufficiency. While the immediate situation appears stable, the complexity of her medical history and the adjustments to her medications make it relatively high-stakes. There's a risk of significant health issues if her conditions aren't managed properly, and the practitioner must ensure careful follow-up.


Medical Specialty: General Medicine
Sample Name: Female Physical Exam - 2

FEMALE PHYSICAL EXAMINATION,HEENT:  Pupils equal, round and reactive to light and accommodation.  Extraocular movements are intact.  Sclerae are anicteric.  TMs are clear bilaterally.  Oropharynx is clear without erythema or exudate.,Neck:  Supple without lymphadenopathy or thyromegaly.  Carotids are silent.  There is no jugular venous distention.,Chest:  Clear to auscultation bilaterally.,Cardiovascular:  Regular rate and rhythm without S3, S4.  No murmurs or rubs are appreciated.  Peripheral pulses are +2 and equal bilaterally in all four extremities.,Abdomen:  Soft, nontender, nondistended with positive bowel sounds.  No masses, hepatomegaly or splenomegaly are appreciated.,GU:  Reveals normal female external genitalia.  Speculum exam reveals vaginal mucosa to be pink and rugous.  Cervix appears normal.  Bimanual exam reveals uterus to be within normal limits.  Adnexa are normal without masses appreciated.  There is no cervical motion tenderness.,Rectal Exam:  Normal rectal tone.  No masses are appreciated.  Hemoccult is negative.,Extremities:  Reveal no clubbing, cyanosis, or edema.,Joint Exam:  Reveals no tenosynovitis.,Integumentary:  Normal breast tissue without lumps or masses.  There are no skin changes over the breasts.  Axillae are free of masses.,Neurologic:  Cranial nerves II through XII are grossly intact.  Motor strength is 5/5 and equal in all four extremities.  Deep tendon reflexes are +2/4 and equal bilaterally.  Patient is alert and oriented times 3.,Psychiatric:  Grossly normal.,Dermatologic:  No lesions or rashes.
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DESCRIPTION: Sample female physical exam.

Sample female physical exam.

general medicine, female physical examination, bimanual exam, heent, hemoccult, ii through xii, breast tissue, cardiovascular, dermatologic, external genitalia, integumentary, joint exam, lymphadenopathy, neck, neurologic, physical examination, rectal exam, skin changes, speculum exam, female physical, extremities, masses, oropharynx,

The situation involves a routine female physical examination described in detailed medical terms. It represents a standard process in general medicine aiming to assess a patient's health status. While the accuracy and thoroughness of documentation is important, it is a low-stakes scenario because it does not indicate any immediate medical concerns or actions requiring urgent intervention.


Medical Specialty: General Medicine
Sample Name: Gen Med Consult - 15

HISTORY OF PRESENT ILLNESS:,  A 50-year-old female comes to the clinic with complaint of mood swings and tearfulness.  This has been problematic over the last several months and is just worsening to the point where it is impairing her work.  Her boss asks her if she was actually on drugs in which she said no.  She stated may be she needed to be, meaning taking some medications.  The patient had been prescribed Wellbutrin in the past and responded well to it; however, at that time it was prescribed for obsessive-compulsive type disorder relating to overeating and therefore her insurance would not cover the medication.  She has not been on any other antidepressants in the past.  She is not having any suicidal ideation but is having difficulty concentrating, rapid mood swings with tearfulness, and insomnia.  She denies any hot flashes or night sweats.  She underwent TAH with BSO in December of 2003.,FAMILY HISTORY: , Benign breast lump in her mother; however, her paternal grandmother had breast cancer.  The patient denies any palpitations, urinary incontinence, hair loss, or other concerns.  She was recently treated for sinusitis.,ALLERGIES:,  She is allergic to Sulfa.,CURRENT MEDICATIONS:,  Recently finished Minocin and Duraphen II DM.,PHYSICAL EXAMINATION:,General:  A well-developed and well-nourished female, conscious, alert, oriented times three in no acute distress.  Mood is dysthymic.  Affect is tearful.,Skin:  Without rash.,Eyes:  PERRLA.  Conjunctivae are clear.,Neck:  Supple with adenopathy or thyromegaly.,Lungs:  Clear.,Heart:  Regular rate and rhythm without murmur.,ASSESSMENT:,1.  Postsurgical menopause.,2.  Mood swings.,PLAN:,  I spent about 30 minutes with the patient discussing treatment options.  I do believe that her moods would greatly benefit from hormone replacement therapy; however, she is reluctant to do this because of family history of breast cancer.  We will try starting her back on Wellbutrin XL 150 mg daily.  She may increase to 300 mg daily after three to seven days.  Samples provided initially.  If she is not obtaining adequate relief from medication alone, we will then suggest that we explore the use of hormone replacement therapy.  I also recommended increasing her exercise.  We will also obtain some screening lab work including CBC, UA, TSH, chemistry panel, and lipid profile.  Follow up here in two weeks or sooner if any other problems.  She is needing her annual breast exam as well.
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DESCRIPTION: Complaint of mood swings and tearfulness.

general medicine, tearfulness, mood swings, menopause, postsurgical menopause, mood swings and tearfulness, hormone replacement therapy, breast cancer, wellbutrin,

The situation presented involves a patient's psychological well-being and the medical management of her symptoms. While the symptoms are clearly impacting her daily life and work, which raises the stakes, the absence of suicidal ideation and the presence of a treatment plan aimed at addressing these issues suggests a moderate level of medical urgency rather than extremely high-stakes. Additionally, the availability of past and new medications to attempt management gives room for intervention. Family history of breast cancer complicates the decision around hormone therapy, but at this point, the primary course of action is substituting medication and recommending lifestyle changes, with monitoring planned.


Medical Specialty: Radiology
Sample Name: Three Views - Ankle

EXAM: , Three views of the right ankle.,INDICATIONS:  ,Pain.,FINDINGS: , Three views of the right ankle are obtained.  There is no evidence of fractures or dislocations.  No significant degenerative changes or destructive osseous lesions of the ankle are noted.  There is a small plantar calcaneal spur.  There is no significant surrounding soft tissue swelling.,IMPRESSION:  ,Negative right ankle.
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DESCRIPTION: Pain.  Three views of the right ankle.  Three views of the right ankle are obtained.

radiology, three views, calcaneal, plantar, spur, osseous, ankle

The provided medical scenario involves interpreting radiology results for an ankle examination. The findings indicate there are no fractures, dislocations, or significant degenerative changes, and the overall impression is a negative right ankle. While the presence of a small calcaneal spur is noted, such findings are relatively common and typically not emergency situations. The primary concern expressed is pain, which, without further abnormalities, suggests this is a low-stakes situation focused on routine diagnostic assessment rather than an immediate or life-threatening condition.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Heart Catheterization, Ventriculography, & Angiography - 2

NAME OF PROCEDURE: , Left heart catheterization with ventriculography, selective coronary arteriographies, successful stenting of the left anterior descending diagonal.,INDICATION:,  Recurrent angina.  History of coronary disease.,TECHNICAL PROCEDURE: , Standard Judkins, right groin.,CATHETERS USED:,  6-French pigtail, 6-French JL4, 6-French JR4.,ANTICOAGULATION: , 2000 of heparin, 300 of Plavix, was begun on Integrilin.,COMPLICATIONS: , None.,STENT: , For stenting we used a 6-French left Judkins guide.  Stent was a 275 x 13 Zeta.,DESCRIPTION OF PROCEDURE: , I reviewed with the patient the pros, cons, alternatives and risks of catheterization and sedation including myocardial infarction, stroke, death, damage to nerve, artery or vein in the leg, perforation of cardiac chamber, resection of an artery, arrhythmia requiring countershock, infection, bleeding, allergy, and need for vascular surgery.  All questions were answered and the patient decided to proceed.,HEMODYNAMIC DATA: , Aortic pressure was within physiologic range.  There was no significant gradient across the aortic valve.,ANGIOGRAPHIC DATA,1.  Ventriculogram:  Left ventricle was of normal size and shape with normal wall motion, normal ejection fraction.,2.  Right coronary artery:  Dominant.  There was a lesion in the proximal portion in the 60% range, insignificant disease distally.,3.  Left coronary artery:  The left main coronary artery showed insignificant disease.  The circumflex arose, showed about 30% proximally.  Left anterior descending arose and the previously placed stent was perfectly patent.  There was a large diagonal branch which showed 90% stenosis in its proximal portion.  There was a lesion in the 30% to 40% range even more proximal.,I reviewed with the patient the options of medical therapy, intervention on the culprit versus bypass surgery.  He desired that we intervene.,Successful stenting of the left anterior descending, diagonal.  The guide was placed in the left main.  We easily crossed the lesion in the diagonal branch of the left anterior descending.  We advanced, applied and post-dilated the 275 x 13 stent.  Final angiography showed 0% residual at the site of previous 90% stenosis.  The more proximal 30% to 40% lesion was unchanged.,CONCLUSION,1.  Successful stenting of the left anterior descending/diagonal.  Initially there was 90% in the diagonal after stenting.  There was 0% residual.  There was a lesion a bit more proximal in the 40% range.,2.  Left anterior descending stent remains patent.,3.  30% in the circumflex.,4.  60% in the right coronary.,5.  Ejection fraction and wall motion are normal.,PLAN: , We have stented the culprit lesion.  The patient will receive a course of aspirin, Plavix, Integrilin, and statin therapy.  We used 6-French Angio-Seal in the groin.  All questions have been answered.  I have discussed the possibility of restenosis, need for further procedures.
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DESCRIPTION: Left heart catheterization with ventriculography, selective coronary arteriographies, successful stenting of the left anterior descending diagonal.

The procedure described is a left heart catheterization with ventriculography, coronary arteriographies, and stenting, which are significant cardiovascular interventions. These procedures are critical for addressing coronary artery disease, and complications such as myocardial infarction, stroke, or death could occur, although none did in this case. Given the patient's history of recurrent angina and coronary disease, the stakes are high as the outcomes directly influence the patient's heart function and overall health. Moreover, the successful outcome was crucial for preventing severe cardiac events. Thus, this situation entails significant stakes related to patient health and procedural success.


Medical Specialty: Neurology
Sample Name: MRI C-Spine - C5-6 Disk Herniation

CC:, Right shoulder pain.,HX: ,This 46 y/o RHF presented with a 4 month history of right neck and shoulder stiffness and pain. The symptoms progressively worsened over the 4 month course. 2 weeks prior to presentation she began to develop numbness in the first and second fingers of her right hand and RUE pain. The later was described as a throbbing pain. She also experienced numbness in both lower extremities and pain in the coccygeal region. The pains worsened at night and impaired sleep. She denied any visual change, bowel or bladder difficulties and symptoms involving the LUE. She occasionally experienced an electric shock like sensation shooting down her spine when flexing her neck (Lhermitte's phenomena). She denied any history of neck/back/head trauma.,She had been taking Naprosyn with little relief.,PMH: ,1) Catamenial Headaches. 2) Allergy to Macrodantin.,SHX/FHX:, Smokes 2ppd cigarettes.,EXAM: ,Vital signs were unremarkable.,CN: unremarkable.,Motor: full strength throughout. Normal tone and muscle bulk.,Sensory: No deficits on LT/PP/VIB/TEMP/PROP testing.,Coord/Gait/Station: Unremarkable.,Reflexes: 2/2 in BUE except 2+ at left biceps. 1+/1+BLE except an absent right ankle reflex.,Plantar responses were flexor bilaterally. Rectal exam: normal tone.,IMPRESSION:, C-spine lesion.,COURSE: ,MRI C-spine revealed a central C5-6 disk herniation with compression of the spinal cord at that level. EMG/NCV showed normal NCV, but 1+ sharps and fibrillations in the right biceps (C5-6), brachioradialis (C5-6), triceps (C7-8) and teres major; and 2+ sharps and fibrillations in the right pronator terres. There was increased insertional activity in all muscles tested on the right side. The findings were consistent with a C6-7 radiculopathy.,The patient subsequently underwent C5-6 laminectomy and her symptoms resolved.
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DESCRIPTION: MRI C-spine to evaluate right shoulder pain - C5-6 disk herniation.

neurology, shoulder pain, stiffness, numbness, lhermitte's phenomena, c-spine lesion, disk herniation, mri c spine, reflexes, biceps, mri, disk, shoulder, spine, herniation,

The situation involves a patient presenting with neurological symptoms, including right shoulder and neck pain, numbness, and Lhermitte's phenomena, which can indicate significant cervical spine issues impacting her nervous system. The MRI results confirm a central C5-6 disk herniation compressing the spinal cord, a potentially severe condition due to its impact on spinal cord function. This was serious enough to warrant surgical intervention (C5-6 laminectomy), which suggests a high-stakes scenario due to the risks associated with spinal surgery and potential for neurological deficits if untreated.


Medical Specialty: Podiatry
Sample Name: Three Views - Foot

EXAM:  ,Three views of the right foot.,REASON FOR EXAM: , Right foot trauma.,FINDINGS: , Three views of the right foot were obtained.  There are no comparison studies.  There is no evidence of fractures or dislocations.  No significant degenerative changes or obstructive osseous lesions were identified.  There are no radiopaque foreign bodies.,IMPRESSION: , Negative right foot.
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DESCRIPTION: Right foot trauma.  Three views of the right foot.  Three views of the right foot were obtained.

podiatry, three views, radiopaque, fractures, foot trauma

The situation involves a diagnostic exam for right foot trauma in the field of podiatry. The examination revealed negative results for fractures, dislocations, and other significant issues. Since the findings are negative and there are no critical injuries or conditions identified, the scenario does not involve life-threatening situations. Therefore, it is not a high-stakes situation.


Medical Specialty: Consult - History and Phy.
Sample Name: Brain Tumor - Consult

REASON FOR CONSULTATION: , I was asked by Dr. X to see the patient in regard to his likely recurrent brain tumor.,HISTORY OF PRESENT ILLNESS: , The patient was admitted for symptoms that sounded like postictal state.  He was initially taken to Hospital.  CT showed edema and slight midline shift, and therefore he was transferred here.  He has been seen by Hospitalists Service.  He has not had a recurrent seizure.  Electroencephalogram shows slowing.  MRI of the brain shows large inhomogeneous infiltrating right frontotemporal neoplasm surrounding the right middle cerebral artery.  There is inhomogeneous uptake consistent with potential necrosis.  He also has had a SPECT image of his brain, consistent with neoplasm, suggesting relatively high-grade neoplasm.  The patient was diagnosed with a brain tumor in 1999.  All details are still not available to us.  He underwent a biopsy by Dr. Y. One of the notes suggested that this was a glioma, likely an oligodendroglioma, pending a second opinion at Clinic.  That is not available on the chart as I dictate.,After discussion of treatment issues with radiation therapist and Dr. Z (medical oncologist), the decision was made to treat him primarily with radiation alone.  He tolerated that reasonably well.  His wife says it's been several years since he had a scan.  His behavior had not been changed, until it changed as noted earlier in this summary.,PAST MEDICAL HISTORY: , He has had a lumbar fusion.  I believe he's had heart disease.  Mental status changes are either due to the tumor or other psychiatric problems.,SOCIAL HISTORY:,  He is living with his wife, next door to one of his children.  He has been disabled since 2001, due to the back problems.,REVIEW OF SYSTEMS: , No headaches or vision issues.  Ongoing heart problems, without complaints.  No weakness, numbness or tingling, except that related to his chronic neck pain.  No history of endocrine problems.  He has nocturia and urinary frequency.,PHYSICAL EXAMINATION: , Blood pressure 146/91, pulse 76.  Normal conjunctivae.  Ears, nose, throat normal.  Neck is supple.  Chest clear.  Heart tones normal.  Abdomen soft.  Positive bowel sounds.  No hepatosplenomegaly.  No adenopathy in the neck, supraclavicular or axillary regions.  Neurologically alert.  Cranial nerves are intact.  Strength is 5/5 throughout.,LABORATORY WORK: , White blood count 10.4, hemoglobin 16, platelets not noted.  Sodium 137, calcium 9.1.,IMPRESSION AND PLAN:,  Likely recurrent low-grade tumor, possibly evolved to a higher grade, given the MRI and SPECT findings.  Dr. X's note suggests discussing the situation in the tumor board on Wednesday.  He is stable enough.  The pause in his care would not jeopardize his current status.  It would be helpful to get old films and pathology from Abbott Northwestern.  However, he likely will need a re-biopsy, as he is highly suspicious for recurrent tumor and radiation necrosis.  Optimizing his treatment would probably be helped by knowing his current grade of tumor.
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DESCRIPTION: The patient was admitted for symptoms that sounded like postictal state.  CT showed edema and slight midline shift.  MRI of the brain shows large inhomogeneous infiltrating right frontotemporal neoplasm surrounding the right middle cerebral artery.

consult - history and phy., spect, electroencephalogram, middle cerebral artery, brain tumor, inhomogeneous, frontotemporal, neoplasm, recurrent

The patient is being evaluated for a potentially recurrent brain tumor, which is a serious medical condition with significant implications for the patient's health and treatment plan. The results of the MRI and SPECT suggest a possible progression to a higher-grade neoplasm. The case involves consultation and decision-making on whether to perform a re-biopsy and discuss treatment options, which are crucial for the patient's ongoing care. Given the potential impact on the patient's prognosis and quality of life, this situation is high-stakes.


Medical Specialty: Surgery
Sample Name: Septorhinoplasty

PREOPERATIVE DIAGNOSIS: , Acquired nasal septal deformity.,POSTOPERATIVE DIAGNOSIS: , Acquired nasal septal deformity.,PROCEDURES:,1.  Open septorhinoplasty with placement of bilateral spreader grafts.,2.  Placement of a radiated rib tip graft.,3.  Placement of a morcellized autogenous cartilage dorsal onlay graft.,4.  Placement of endogen, radiated collagen dorsal onlay graft.,5.  Placement of autogenous cartilage columellar strut graft.,6.  Bilateral lateral osteotomies.,7.  Takedown of the dorsal hump with repair of the bony and cartilaginous open roof deformities.,8.  Fracture of right upper lateral cartilage.,ANESTHESIA:  ,General endotracheal tube anesthesia.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:  ,100 mL.,URINE OUTPUT:,  Not recorded.,SPECIMENS:,  None.,DRAINS: , None.,FINDINGS:  ,1.  The patient had a marked dorsal hump, which was both bony and cartilaginous in nature.,2.  The patient had marked hypertrophy of his nasalis muscle bilaterally contributing to the soft tissue dorsal hump.,3.  The patient had a C-shaped deformity to the left before he had tip ptosis.,INDICATIONS FOR PROCEDURE: , The patient is a 22-year-old Hispanic male who is status post blunt trauma to the nose approximately 9 months with the second episode 2 weeks following and suffered a marked dorsal deformity.  The patient was evaluated, but did not complain of nasal obstruction, and his main complaint was his cosmetic deformity.  He was found to have a C-shaped deformity to the left as well as some tip ptosis.  The patient was recommended to undergo an open septorhinoplasty to repair of this cosmetic defect.,OPERATION IN DETAIL: , After obtaining a full consent from the patient, identified the patient, prepped with Betadine, brought to the operating room and placed in the supine position on the operating table.  The appropriate Esmarch was placed; and after adequate sedation, the patient was subsequently intubated without difficulty.  The endotracheal tube was then secured, and the table was then turned clockwise to 90 degrees.  Three Afrin-soaked cottonoids were then placed in nasal cavity bilaterally.  The septum was then injected with 3 mL of 1% lidocaine with 1:100,000 epinephrine in the subperichondrial plane bilaterally.  Then, 50 additional mL of 1% lidocaine with 1:100,000 epinephrine was then injected into the nose in preparation for an open rhinoplasty.,Procedure was begun by first marking a columellar incision.  This incision was made using a #15 blade.  A lateral transfixion incision was then made bilaterally using a #15 blade, and then, the columellar incision was completed using iris scissors with care not to injure the medial crura.  However, there was a dissection injury to the left medial crura.  Dissection was then taken in the subperichondrial plane over the lower lateral cartilages and then on to the upper lateral cartilage.  Once we reached the nasal bone, a Freer was used to elevate the tissue overlying the nasal bone in a subperiosteal fashion.  Once we had completed exposure of the bony cartilaginous structures, we appreciated a very large dorsal hump, which was made up of both a cartilaginous and bony portions.  There was also an obvious fracture of the right upper lateral cartilage.  There was also marked hypertrophy what appeared to be in the nasalis muscle in the area of the dorsal hump.  The skin was contributing to the patient's cosmetic deformity.  In addition, we noted what appeared to be a small mucocele coming from the area of the fractured cartilage on the right upper lateral cartilage.  This mucocele was attempted to be dissected free, most of which was removed via dissection.  We then proceeded to remove takedown of the dorsal hump using a Rubin osteotome.  The dorsal hump was taken down and passed off the table.  Examination of the specimen revealed the marking amount of scar tissue at the junction of the bone and cartilage.  This was passed off to use later for possible onlay grafts.  There was now a marked open roof deformity of the cartilage and bony sprue.  A septoplasty was then performed throughout and a Kelly incision on the right side.  Subperichondrial planes were elevated on the right side, and then, a cartilage was incised using a caudal and subperichondrial plane elevated on the left side.  A 2 x 3-cm piece of the cardinal cartilage was then removed with care to leave at least 1 cm dorsal and caudal septal strut.  This cartilage was passed down the table and then 2 columellar strut grafts measuring approximately 15 mm in length were then used and placed to close the bony and cartilaginous open roof deformities.  The spreader grafts were sewn in place using three interrupted 5-0 PDS sutures placed in the horizontal fashion bilaterally.  Once these were placed, we then proceeded to work on the bony open roof.  Lateral osteotomies were made with 2-mm osteotomes bilaterally.  The nasal bones were then fashioned medially to close the open roof deformity, and this reduced the width of the bony nasal dorsum.  We then proceeded to the tip.  A cartilaginous strut was then fashioned from the cartilaginous septum.  It was approximately 15 mm long.  This was placed, and a pocket was just formed between the medial crura.  This pocket was taken down to the nasal spine, and then, the strut graft was placed.  The intradermal sutures were then placed using interrupted 5-0 PDS suture to help to provide more tip projection and definition.  The intradermal sutures were then placed to help to align the nasal tip.  The cartilage strut was then sutured in place to the medial crura after elevating the vestibular skin off the medial crura in the area of the plane suturing.  Prior to the intradermal suturing, the vestibular skin was also taken off in the area of the dome.,The columellar strut was then sutured in place using interrupted 5-0 PDS suture placed in a horizontal mattress fashion with care to help repair the left medial crural foot.  The patient had good tip support after this maneuver.  We then proceeded to repair the septal deformity created by taking down the dorsal hump with the Rubin osteotome.  This was done by crushing the remaining cartilage in the morcellizer and then wrapping this crushed cartilage in endogen, which is a radiated collagen.  The autogenous cartilage was wrapped in endogen in a sandwich fashion, and then, a 4-0 chromic suture was placed through this to help with placement of the dorsal onlay graft.,The dorsal onlay was then sewn into position, and then, the 4-0 chromic suture was brought out through this externally to help the superior placement of the dorsal onlay graft.  Once we were happy with the position of the dorsal onlay graft, the graft was then sutured in place using two interrupted 4-0 fast-absorbing sutures inferiorly just above the superior edge of the lower lateral cartilages.  Once we were happy with the placement of this, we did need to take down some of the bony dorsal hump laterally, and this was done using a #6 and then followed with a #3 push grafts.  This wrapping was performed prior to placement of the dorsal onlay graft.,I went through content with the dorsal onlay graft and the closure of the roof deformities as well as placement of the columellar strut, we then felt the patient could use a bit more tip projection; and therefore, we fashioned a radiated rib into a small octagon; and this was sutured in place over the tip using two interrupted 5-0 PDS sutures.,At this point, we were happy with the test results, although the patient did have significant amount of fullness in the dorsal hump area due to soft tissue thick and fullness.  There do not appear to be any other pathology causing the patient dorsal hump and therefore, we felt we have achieved the best cosmetic result at this point.  The septum was reapproximated using a fast-absorbing 4-0 suture and a Keith needle placed in the mattress fashion.  The Kelly incision was closed using two interrupted 4-0 fast-absorbing gut suture.  Doyle splints were then placed within the nasal cavity and secured to the inferior septum using a 3-0 monofilament suture.  The columellar skin was reapproximated using interrupted 6-0 nylon sutures, and the marginal incision of the vestibular skin was closed using interrupted 4-0 chromic sutures.,At the end of the procedure, all sponge, needle, and instrument counts were correct.  A Denver external splint was then applied.  The patient was awakened, extubated, and transported to Anesthesia Care Unit in good condition.
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DESCRIPTION: Open septorhinoplasty with placement of bilateral spreader grafts.  Bilateral lateral osteotomies.

The detailed surgery described here involves a septorhinoplasty with multiple specific procedures to correct an acquired nasal septal deformity mainly for cosmetic reasons. The operation includes various graft placements, osteotomies, and significant reconstruction of nasal structures. Although there are inherent risks associated with any surgical procedure, the surgery is planned, with no intraoperative complications noted, and the patient is in good condition post-surgery. The stakes are moderate due to the invasive nature of the surgery and the complexity of reconstructive work, but not critical as the primary objective is aesthetic improvement, not life-saving intervention.