Medical Specialty: Gastroenterology
Sample Name: Cholecystitis - Discharge Summary

REASON FOR ADMISSION: , Cholecystitis with choledocholithiasis.,DISCHARGE DIAGNOSES: , Cholecystitis, choledocholithiasis.,ADDITIONAL DIAGNOSES,1.  Status post roux-en-y gastric bypass converted to an open procedure in 01/07.,2.  Laparoscopic paraventral hernia in 11/07.,3.  History of sleep apnea with reversal after 100-pound weight loss.,4.  Morbid obesity with bmi of 39.4.,PRINCIPAL PROCEDURE:,  Laparoscopic cholecystectomy with laparoscopy converted to open common bile duct exploration and stone extraction.,HOSPITAL COURSE: , The patient is a 33-year-old female admitted with elevated bilirubin and probable common bile duct stone.  She was admitted through the emergency room with abdominal pain, elevated bilirubin, and gallstones on ultrasound with a dilated common bile duct.  She subsequently went for a HIDA scan to rule out cholecystitis.  Gallbladder was filled but was unable to empty into the small bowel consistent with the common bile duct blockage.  She was taken to the operating room that night for laparoscopic cholecystectomy.  We proceeded with laparoscopic cholecystectomy and during the cholangiogram there was no contrast.  It was able to be extravasated into the duodenum with the filling defect consistent with the distal common bile duct stone.  The patient had undergone a Roux-en-Y gastric bypass but could not receive an ERCP and stone extraction, therefore, common bile duct exploration was performed and a stone was extracted.  This necessitated conversion to an open operation.  She was transferred to the medical surgical unit postoperatively.  She had a significant amount of incisional pain following morning, but no nausea.  A Jackson-Pratt drain, which was left in place in two places showed serosanguineous fluid.  White blood cell count was down to 7500 and bilirubin decreased to 2.1.  Next morning she was started on a liquid diet.  Foley catheter was discontinued.  There was no evidence of bile leak from the drains.  She was advanced to a regular diet on postoperative day #3, which was 12/09/07.  The following morning she was tolerating regular diet.  Her bowels had begun to function, and she was afebrile with her pain control with oral pain medications.  Jackson-Pratt drain was discontinued from the wound.  The remaining Jackson-Pratt drain was left adjacent to her cystic duct.  Following morning, her laboratory studies were better.  Her bilirubin was down to normal and white blood cell count was normal with an H&H of 9 and 26.3.  Jackson-Pratt drain was discontinued, and she was discharged home.  Followup was in 3 days for staple removal.  She was given iron 325 mg p.o. t.i.d. and Lortab elixir 15 cc p.o. q.4 h. p.r.n. for pain.
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DESCRIPTION: Cholecystitis with choledocholithiasis.   Laparoscopic cholecystectomy with laparoscopy converted to open common bile duct exploration and stone extraction.

gastroenterology, laparoscopy, common bile duct exploration, laparoscopic cholecystectomy, bile duct, choledocholithiasis, cholecystectomy, cholecystitis, laparoscopic, hernia

The patient's condition involved cholecystitis with choledocholithiasis, which required surgical intervention. Although this condition can be serious and necessitated converting a laparoscopic procedure to an open surgery, the discharge summary indicates that the surgery was successful, and the patient was recovering well without major complications post-operation. The transition to a regular diet, the recovery of normal lab values, and the patient's discharge home further suggest the acute issue was addressed. However, the complexity of the case, prior medical history, and need for significant pain management indicates moderate stakes in ensuring proper follow-up and management.


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

Medical Specialty: Lab Medicine - Pathology
Sample Name: Pathology - Prostate

SPECIMENS:,1.  Pelvis-right pelvic obturator node.,2.  Pelvis-left pelvic obturator node.,3.  Prostate.,POST-OPERATIVE DIAGNOSIS: , Adenocarcinoma of prostate, erectile dysfunction.,DIAGNOSTIC OPINION:,1.  Adenocarcinoma, Gleason score 9, with tumor extension to periprostatic tissue, margin involvement, and tumor invasion to seminal vesicle, prostate.,2.  No evidence of metastatic carcinoma, right pelvic obturator lymph node.,3.  Metastatic adenocarcinoma, left obturator lymph node; see description.,CLINICAL HISTORY: , None listed.,GROSS DESCRIPTION:,Specimen #1 labeled "right pelvic obturator lymph nodes" consists of two portions of adipose tissue measuring 2.5 x 1x 0.8 cm and 2.5 x 1x 0.5 cm.  There are two lymph nodes measuring 1 x 0.7 cm and 0.5 x 0.5 cm.  The entire specimen is cut into several portions and totally embedded.,Specimen #2 labeled "left pelvic obturation lymph nodes" consists of an adipose tissue measuring 4 x 2 x 1 cm.  There are two lymph nodes measuring 1.3 x 0.8 cm and 1 x 0.6 cm.  The entire specimen is cut into 1 cm.  The entire specimen is cut into several portions and totally embedded.,Specimen #3 labeled "prostate" consists of a prostate.  It measures 5 x 4.5 x 4 cm.  The external surface shows very small portion of seminal vesicles attached in both sides with tumor induration.  External surface also shows tumor induration especially in right side.  External surface is stained with green ink.  The cut surface shows diffuse tumor induration especially in right side.  The tumor appears to extend to excision margin.  Multiple representative sections are made.,MICROSCOPIC DESCRIPTION:,Section #1 reveals lymph node.  There is no evidence of metastatic carcinoma.,Section #2 reveals lymph node with tumor metastasis in section of large lymph node as well as section of small lymph node.,Section #3 reveals adenocarcinoma of prostate.  Gleason's score 9 (5+4).  The tumor shows extension to periprostatic tissue as well as margin involvement.  Seminal vesicle attached to prostate tissue shows tumor invasion.  Dr. XXX reviewed the above case.  His opinion agrees with the above diagnosis.,SUMMARY:,A.  Adenocarcinoma of prostate, Gleason's score 9, with both lobe involvement and seminal vesicle involvement (T3b).,B.  There is lymph node metastasis (N1).,C.  Distant metastasis cannot be assessed (MX).,D.  Excision margin is positive and there is tumor extension to periprostatic tissue.
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DESCRIPTION: Prostate adenocarcinoma and erectile dysfunction - Pathology report.

lab medicine - pathology, pelvic obturator node, erectile dysfunction, seminal vesicle, prostate, lymph node, specimen, section, adenocarcinoma of prostate, pelvic obturator, tumor, lymph, node, specimens, adenocarcinoma,

The pathology report indicates a serious case of prostate adenocarcinoma with a high Gleason score of 9, extension beyond the prostate, seminal vesicle involvement, and lymph node metastasis. These factors suggest an advanced stage of cancer, which generally requires urgent and comprehensive treatment. The patient's clinical outcome and quality of life can be heavily impacted by such a diagnosis, making it a high-stakes situation for medical professionals involved in the patient's care.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Radiology
Sample Name: CT Abdomen & Pelvis - 5

EXAM: , CT abdomen without contrast and pelvis without contrast, reconstruction.,REASON FOR EXAM: , Right lower quadrant pain, rule out appendicitis.,TECHNIQUE:  ,Noncontrast CT abdomen and pelvis.  An intravenous line could not be obtained for the use of intravenous contrast material.,FINDINGS: , The appendix is normal.  There is a moderate amount of stool throughout the colon.  There is no evidence of a small bowel obstruction or evidence of pericolonic inflammatory process.  Examination of the extreme lung bases appear clear, no pleural effusions.  The visualized portions of the liver, spleen, adrenal glands, and pancreas appear normal given the lack of contrast.  There is a small hiatal hernia.  There is no intrarenal stone or evidence of obstruction bilaterally.  There is a questionable vague region of low density in the left anterior mid pole region, this may indicate a tiny cyst, but it is not well seen given the lack of contrast.  This can be correlated with a followup ultrasound if necessary.  The gallbladder has been resected.  There is no abdominal free fluid or pathologic adenopathy.  There is abdominal atherosclerosis without evidence of an aneurysm.,Dedicated scans of the pelvis disclosed phleboliths, but no free fluid or adenopathy.  There are surgical clips present.  There is a tiny airdrop within the bladder.  If this patient has not had a recent catheterization, correlate for signs and symptoms of urinary tract infection.,IMPRESSION:,1.Normal appendix.,2.Moderate stool throughout the colon.,3.No intrarenal stones.,4.Tiny airdrop within the bladder.  If this patient has not had a recent catheterization, correlate for signs and symptoms of urinary tract infection.  The report was faxed upon dictation.
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DESCRIPTION: CT abdomen without contrast and pelvis without contrast, reconstruction.

radiology, reconstruction, appendicitis, urinary tract infection, ct abdomen, abdomen, ct, pelvis, contrast, noncontrast,

The CT scan indicates that the patient does not have appendicitis, which was the primary concern. The findings such as a normal appendix and no evidence of small bowel obstruction reassure that there is no immediate life-threatening condition. However, there is a suggestion to follow up on a potential urinary tract infection, and issues like the stool presence and hiatal hernia, which, although not critical by themselves, still require proper medical attention. The stakes are not extremely high since there’s no immediate danger, but the situation shouldn’t be entirely ignored either.


Medical Specialty: Gastroenterology
Sample Name: Cholecystectomy Laparoscopic

PREOPERATIVE DIAGNOSIS: ,Gallstone pancreatitis.,POSTOPERATIVE DIAGNOSIS: , Gallstone pancreatitis.,PROCEDURE PERFORMED: , Laparoscopic cholecystectomy.,ANESTHESIA: , General endotracheal and local injectable Marcaine.,ESTIMATED BLOOD LOSS: , Minimal.,SPECIMEN: , Gallbladder.,COMPLICATIONS:  ,None.,OPERATIVE FINDINGS: , Video laparoscopy revealed dense omental adhesions surrounding the gallbladder circumferentially.  These dense adhesions were associated with chronic inflammatory edematous changes.  The cystic duct was easily identifiable and seen entering into the gallbladder and clipped two proximally and one distally.  The cystic artery was an anomalous branch that was anterior to the cystic duct and was identified, clipped with two clips proximally and one distally.  The remainder of the evaluation of the abdomen revealed no evidence of nodularity or masses in the liver.  There was no evidence of adhesions from the abdominal wall to the liver.  The remainder of the abdomen was unremarkable.,BRIEF HISTORY:  ,This is a 17-year-old African-American female who presented to ABCD General Hospital on 08/20/2003 with complaints of intractable right upper quadrant abdominal pain.  She had been asked to follow up and scheduled for surgery previously.  Her pain had now been intractable associated with anorexia.  She was noted on physical examination to be afebrile; however, she was having severe right upper quadrant pain with examination as well as a Murphy's sign and voluntary guarding with examination.  Her transaminases were markedly elevated.  She also developed pancreatitis secondary to gallstones.  Her common bile duct was dilated to 1 cm with no evidence of wall thickening, but evidence of cholelithiasis.  She was seen by the gastroenterologist and underwent a sphincterotomy with balloon extraction of gallstones secondary to choledocholithiasis.  Following this, she was scheduled for operative laparoscopic cholecystectomy.  Her parents were explained the risks, benefits, and complications of the procedure.  She gave us informed consent to proceed with surgery.,OPERATIVE PROCEDURE:  ,The patient brought to the operative suite and placed in the supine position.  Preoperatively, the patient received IV antibiotics of Ancef, sequential compression devices and subcutaneous heparin.  The abdomen was prepped and draped in the normal sterile fashion with Betadine solution.  Utilizing a #15 blade scalpel, a transverse infraumbilical incision was created.  Utilizing a Veress needle with anterior traction on the anterior abdominal wall with a towel clamp, the Veress needle was inserted without difficulty.  Hanging water drop test was performed with notable air aspiration through the Veress needle and the saline passed through the Veress needle without difficulty.  The abdomen was then insufflated to 15 mmHg with carbon-dioxide.  Once the abdomen was sufficiently insufflated, a #10 mm bladed trocar was inserted into the abdomen without difficulty.  Video laparoscope was inserted and the above notable findings were identified in the operative findings.  The patient to proceed with laparoscopic cholecystectomy was decided and a subxiphoid port was placed.  A #15 bladed scalpel was used to make a transverse incision in the subxiphoid region within the midline.  The trocar was then inserted into the abdomen under direct visualization with the video laparoscope and seen to go to the right of falciform ligament.  Next, two 5 mm trocars were inserted under direct visualization, one in the midclavicular and one in the anterior midaxillary line.  These were inserted without difficulty.  The liver edge was lifted and revealed a markedly edematous gallbladder with severe omental adhesions encapsulating the gallbladder.  Utilizing Endoshears scissor, a plane was created circumferentially to the dome of the gallbladder to allow assistance and dissection of these dense adhesions.  Next, the omental adhesions adjacent to the infundibulum were taken down and allowed to expose the cystic duct.  A small vessel was seen anterior to the cystic duct and this was clipped two proximally and one distally and noted to be an anomalous arterial branch.  This was transected with Endoshears scissor and visualized the pulsatile branch with two clips securely in place.  Next, the cystic duct was carefully dissected with Maryland dissectors and was visualized clearly both anterior and posteriorly.  Endoclips were placed two proximally and one distally and then the cystic duct was transected with Endoshears scissor.,Once the clips were noted to be in place, utilizing electrocautery another Dorsey dissector was used to carefully dissect the gallbladder off the liver bed wall.  The gallbladder was removed and the bleeding from the gallbladder wall was easily controlled with electrocautery.  The abdomen was then irrigated with copious amounts of normal saline.  The gallbladder was grasped with a gallbladder grasper and removed from the subxiphoid port.  There was noted to be gallstones within the gallbladder.  Once the abdomen was re-insufflated after removing the gallbladder and copious irrigation was performed, all ports were then removed under direct visualization with no evidence of bleeding from the anterior abdominal wall.  Utilizing #0 Vicryl suture, a figure-of-eight was placed to the subxiphoid and infraumbilical fascia and this was approximated without difficulty.  The subxiphoid port was irrigated with copious amounts of normal saline prior to closure of the fascia.  A #4-0 Vicryl suture was used to approximate all incisions.  The incisions were then injected with local injectable 0.25% Marcaine.  All ports were then cleaned dry.  Steri-Strips were placed across and sterile pressure dressings were placed on top of this.  The patient tolerated the entire procedure well.  She was transferred to the Postanesthesia Care Unit in stable condition.  She will be followed closely in the postoperative course in General Medical Floor.
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DESCRIPTION: Laparoscopic cholecystectomy.  Gallstone pancreatitis.  Video laparoscopy revealed dense omental adhesions surrounding the gallbladder circumferentially.

gastroenterology, gallstone, gallbladder, pancreatitis, anterior abdominal wall, video laparoscope, laparoscopic cholecystectomy, omental adhesions, veress needle, cystic duct, injectable, adhesions, cholecystectomy, laparoscopic, abdomen

Laparoscopic cholecystectomy is a common surgical procedure used to treat gallbladder-related issues such as gallstones, which in this case led to gallstone pancreatitis. While common, this procedure involves general anesthesia and surgical intervention, which inherently carry risks such as bleeding, infection, and reaction to anesthesia. The coordination of surgical team, potential need for conversions to open surgery, and postoperative care also add layers of complexity. Moreover, the presence of dense adhesions and chronic inflammatory changes noted in the findings could complicate the surgery, although the actual procedure was completed without complications. Given these considerations, the situation is moderate to high-stakes in the medical field.


Medical Specialty: Surgery
Sample Name: Abscess Excision

PREOPERATIVE DIAGNOSIS: , Recurrent re-infected sebaceous cyst of abdomen.,POSTOPERATIVE DIAGNOSES:,1.  Abscess secondary to retained foreign body.,2.  Incisional hernia.,PROCEDURES,1.  Excision of abscess, removal of foreign body.,2.  Repair of incisional hernia.,ANESTHESIA: , LMA.,INDICATIONS: , Patient is a pleasant 37-year-old gentleman who has had multiple procedures including a laparotomy related to trauma.  The patient has had a recurrently infected cyst of his mass at the superior aspect of his incision, which he says gets larger and then it drains internally, causing him to be quite ill.  He presented to my office and I recommended that he undergo exploration of this area and removal.  The procedure, purpose, risks, expected benefits, potential complications, and alternative forms of therapy were discussed with him and he was agreeable to surgery.,FINDINGS:,  The patient was found upon excision of the cyst that it contained a large Prolene suture, which is multiply knotted as it always is; beneath this was a very small incisional hernia, the hernia cavity, which contained omentum; the hernia was easily repaired.,DESCRIPTION OF PROCEDURE: , The patient was identified, then taken into the operating room, where after induction of an LMA anesthetic, his abdomen was prepped with Betadine solution and draped in sterile fashion.  The puncta of the wound lesion was infiltrated with methylene blue and peroxide.  The lesion was excised and the existing scar was excised using an ellipse and using a tenotomy scissors, the cyst was excised down to its base.  In doing so, we identified a large Prolene suture within the wound and followed this cyst down to its base at which time we found that it contained omentum and was in fact overlying a small incisional hernia.  The cyst was removed in its entirety, divided from the omentum using a Metzenbaum and tying with 2-0 silk ties.  The hernia repair was undertaken with interrupted 0 Vicryl suture with simple sutures.  The wound was then irrigated and closed with 3-0 Vicryl subcutaneous and 4-0 Vicryl subcuticular and Steri-Strips.  Patient tolerated the procedure well.  Dressings were applied and he was taken to recovery room in stable condition.
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DESCRIPTION: Excision of abscess, removal of foreign body.  Repair of incisional hernia.  Recurrent re-infected sebaceous cyst of abdomen.  Abscess secondary to retained foreign body and incisional hernia.

surgery, sebaceous cyst, prolene suture, incisional hernia, incisional, abscess, hernia, abdomen, omentum, excision, cyst,

The surgical procedure involves excising an abscess caused by a foreign body and repairing a hernia, which are common surgical practices. While important for the patient's health and comfort, the procedure itself, according to the description, seems routine and was completed without issues. The stakes are moderate because it involves surgery, but the patient is stable and the conditions are not life-threatening at this point. However, it requires careful management to prevent future complications.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Bronchoscopy - 6

PREOPERATIVE DIAGNOSIS: , Hypoxia and increasing pulmonary secretions.,POSTOPERATIVE DIAGNOSIS: , Hypoxia and increasing pulmonary secretions.,OPERATION: , Bronchoscopy.,ANESTHESIA: , Moderate bedside sedation.,COMPLICATIONS:,  None.,FINDINGS:,  Abundant amount of clear thick secretions throughout the main airways.,INDICATIONS:,  The patient is a 43-year-old gentleman who has been in the ICU for several days following resection of small bowel for sequelae of SMV occlusion.  This morning, the patient developed worsening hypoxia with abundant sputum production requiring frequent suctioning from his ET tube.  The patient also had new-appearing atelectasis versus infiltrates in the right lower lobe of his lung on chest x-ray.  Given these findings, it was felt that bronchoscopy could further define source of secretions and send more appropriate specimen for culture if need be.,OPERATION:,  The patient was given additional fentanyl, Versed as well as paralytics for the procedure.  Small bronchoscope was inserted through the ET tube and to the trachea to the level of carina.  There was noted to be thick clear secretions adherent to the trachea walls as well as into the right mainstem bronchus.  Extensive secretions extended down into the secondary airways.  This was lavaged with saline and suctioned dry.  There is no overt specific occlusion of airways, nor was there any purulent-appearing sputum.  The bronchoscope was then advanced into the left mainstem bronchus, and there was noted to be a small amount of similar-appearing secretions which was likewise suctioned and cleaned.  The bronchoscope was removed, and the patient was increased to PEEP of 10 on the ventilator.  Please note that prior to starting bronchoscopy, he was pre oxygenated with 100% O2.  The patient tolerated the procedure well and lavage specimen was sent for gram stain as well as routine culture.
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DESCRIPTION: Bronchoscopy for hypoxia and increasing pulmonary secretions

cardiovascular / pulmonary, pulmonary secretions, bronchoscopy, hypoxia, peep, smv occlusion, atelectasis, bedside sedation, bronchoscope, chest x-ray, mainstem, right lower lobe, mainstem bronchus,

This situation involves a patient in the ICU with hypoxia and increasing pulmonary secretions, who underwent a bronchoscopy. The procedure was done to identify the source of secretions and collect samples for culture. Given the patient's condition in the ICU and the recent surgical history, the stakes are fairly high as it involves respiratory issues that could affect breathing and oxygen levels. However, the patient tolerated the procedure well and there were no complications mentioned.


Medical Specialty: Psychiatry / Psychology
Sample Name: Psych Consult - Alcohol Withdrawal

REASON FOR CONSULT:,  Evaluation of alcohol withdrawal and dependance as well as evaluation of anxiety.,HISTORY OF PRESENT ILLNESS: , This is a 50-year-old male who was transferred from Sugar Land ER to ABCD Hospital for admission to the MICU for acute alcohol withdrawal.  The patient had been on a drinking binge for the past 12 days prior to admission and had not been eating.  He reported that he called 911 secondary to noticing bilious vomiting and dry heave.  The patient has been drinking for the past 25 years and has noted it to be a problem for at least the past 3 years.  He has been away from work secondary to alcohol cravings and drinking.  He has also experienced marital and family conflict as a result of his drinking habit.  On average, the patient drinks 5 to 8 glasses or cups of vodka or rum per day, and on the weekend, he tends to drink more heavily.  He reports a history of withdrawal symptoms, but denied history of withdrawal seizures.  His longest period of sobriety was one year, and this was due to the assistance of attending AA meetings.  The patient reports problems with severe insomnia, more so late insomnia and low self esteem as a result of feeling guilty about what he has done to his family due to his drinking habit.  He reports anxiety that is mostly related to concern about his wife's illness and fear of his wife leaving him secondary to his drinking habits.  He denies depressive symptoms.  He denies any psychotic symptoms or perceptual disturbances.  There are no active symptoms of withdrawal at this time.,PAST PSYCHIATRIC HISTORY: , There are no previous psychiatric hospitalizations or evaluations.  The patient denies any history of suicidal attempts.  There is no history of inpatient rehabilitation programs.  He has attended AA for periodic moments throughout the past few years.  He has been treated with Antabuse before.,PAST MEDICAL HISTORY:,  The patient has esophagitis, hypertension, and fatty liver (recently diagnosed).,MEDICATIONS: , His outpatient medications include Lotrel 30 mg p.o. q.a.m. and Restoril 30 mg p.o. q.h.s.,Inpatient medications are Vitamin supplements, potassium chloride, Lovenox 40 mg subcutaneously daily, Lactulose 30 mL q.8h., Nexium 40 mg IV daily, Ativan 1 mg IV p.r.n. q.6-8h.,ALLERGIES:,  No known drug allergies.,FAMILY HISTORY: , Distant relatives with alcohol dependance.  No other psychiatric illnesses in the family.,SOCIAL HISTORY:,  The patient has been divorced twice.  He has two daughters one from each marriage, ages 15 and 22.  He works as a geologist at Petrogas.  He has limited contact with his children.  He reports that his children's mothers have turned them against him.  He and his wife have experienced marital discord secondary to his alcohol use.  His wife is concerned that he may loose his job because he has skipped work before without reporting to his boss.  There are no other illicit drugs except alcohol that the patient reports.,PHYSICAL EXAMINATION:,  VITAL SIGNS:  Temperature 98, pulse 89, and respiratory rate 20, and blood pressure is 129/83.,MENTAL STATUS EXAMINATION:,  This is a well-groomed male.  He appears his stated age.  He is lying comfortably in bed.  There are no signs of emotional distress.  He is pleasant and engaging.  There are no psychomotor abnormalities.  No signs of tremulousness.  His speech is with normal rate, volume, and inflection.  Mood is reportedly okay.  Affect euthymic.  Thought content, no suicidal or homicidal ideations.  No delusions.  Thought perception, there are no auditory or visual hallucinations.  Thought process, Logical and goal directed.  Insight and judgment are fair.  The patient knows he needs to stop drinking and knows the hazardous effects that drinking will have on his body.,LABORATORY DATA:,  CBC:  WBC 5.77, H&H 14 and 39.4 respectively, and platelets 102,000.  BMP:  Sodium 140, potassium 3, chloride 104, bicarbonate 26, BUN 13, creatinine 0.9, glucose 117, calcium 9.5, magnesium 2.1, phosphorus 2.9, PT 13.4, and INR 1.0.  LFTs:  ALT 64, AST 69, direct bilirubin 0.5, total bilirubin 1.3, protein 5.8, and albumin 4.2.  PFTs within normal limits.,IMAGING:,  CAT scan of the abdomen and pelvis reveals esophagitis and fatty liver.  No splenomegaly.,ASSESSMENT:,  This is a 50-year-old male with longstanding history of alcohol dependence admitted secondary to alcohol withdrawal found to have derangement in liver function tests and a fatty liver.  The patient currently has no signs of withdrawal.  The patient's anxiety is likely secondary to situation surrounding his wife and their marital discord and the effect of chronic alcohol use.  The patient had severe insomnia that is likely secondary to alcohol use.  Currently, there are no signs of primary anxiety disorder in this patient.,DIAGNOSES:,  Axis I:  Alcohol dependence.,Axis II:  Deferred.,Axis III:  Fatty liver, esophagitis, and hypertension.,Axis IV:  Marital discord, estranged from children.,Axis V:  Global assessment of functioning equals 55.,RECOMMENDATIONS:,1.  Continue to taper off p.r.n. Ativan and discontinue all Ativan prior to discharge, benzodiazepine use, also on the same receptor as alcohol and prolonged use can cause relapse in the patient.  Discontinue outpatient Restoril.  The patient has been informed of the hazards of using benzodiazepines along with alcohol.,2.  Continue Alcoholics Anonymous meetings to maintain abstinence.,3.  Recommend starting Campral 666 mg p.o. t.i.d. to reduce alcohol craving.,4.  Supplement with multivitamin, thiamine, and folate upon discharge and before.  Marital counseling strongly advised as well as individual therapy for patient once sobriety is reached.  Referral has been given to the patient and his wife for the sets of counseling #713-263-0829.,5.  Alcohol education and counseling provided during consultation.,6.  Trazodone 50 mg p.o. q.h.s. for insomnia.,7.  Follow up with PCP in 1 to 2 weeks.
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DESCRIPTION: Psychiatric consultation for alcohol withdrawal and dependance.

The situation is high-stakes due to several health and social factors. The patient is hospitalized for acute alcohol withdrawal, which can be life-threatening if not managed properly. His long-term alcohol dependence has led to medical issues like fatty liver and hypertension, which require careful monitoring and intervention. Additionally, the social and emotional implications, such as marital discord and potential job loss, heighten the stakes. These factors combined necessitate a comprehensive and carefully coordinated medical and psychological treatment plan.


Medical Specialty: Radiology
Sample Name: EMG/Nerve Conduction Study - 3

HISTORY: , The patient is a 56-year-old right-handed female with longstanding intermittent right low back pain, who was involved in a motor vehicle accident in September of 2005.  At that time, she did not notice any specific injury.  Five days later, she started getting abnormal right low back pain.  At this time, it radiates into the buttocks down the posterior aspect of her thigh and into the right lateral aspect of her calf.  Symptoms are worse when sitting for any length of time, such as driving a motor vehicle.  Mild symptoms when walking for long periods of time.  Relieved by standing and lying down.  She denies any left leg symptoms or right leg weakness.  No change in bowel or bladder function.  Symptoms have slowly progressed.  She has had Medrol Dosepak and analgesics, which have not been very effective.  She underwent a spinal epidural injection, which was effective for the first few hours, but she had recurrence of the pain by the next day.  This was done four and a half weeks ago.,On examination, lower extremities strength is full and symmetric.  Straight leg raising is normal.,OBJECTIVE:,  Sensory examination is normal to all modalities.  Full range of movement of lumbosacral spine.  Mild tenderness over lumbosacral paraspinal muscles and sacroiliac joint.  Deep tendon reflexes are 2+ and symmetric at the knees, 2 at the left ankle and 1+ at the right ankle.,NERVE CONDUCTION STUDIES:,  Motor and sensory distal latencies, evoked response, amplitudes, conduction velocities, and F-waves are normal in the lower extremities.  Right tibial H-reflex is slightly prolonged when compared to the left tibial H-reflex.,NEEDLE EMG:,  Needle EMG was performed in both lower extremities and lumbosacral paraspinal muscles using the disposable concentric needle.  It revealed increased insertional activity in the right mid and lower lumbosacral paraspinal muscles as well as right peroneus longus muscle.  There were signs of chronic denervation in right tibialis anterior, peroneus longus, gastrocnemius medialis, and left gastrocnemius medialis muscles.,IMPRESSION: , This electrical study is abnormal.  It reveals the following:,1.  A mild right L5 versus S1 radiculopathy.,2.  Left S1 nerve root irritation.  There is no evidence of active radiculopathy.,3.  There is no evidence of plexopathy, myopathy or peripheral neuropathy.,MRI of the lumbosacral spine was personally reviewed and reveals bilateral L5-S1 neuroforaminal stenosis, slightly worse on the right.  Results were discussed with the patient and her daughter.  I would recommend further course of spinal epidural injections with Dr. XYZ.  If she has no response, then surgery will need to be considered.  She agrees with this approach and will followup with you in the near future.
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DESCRIPTION: A right-handed female with longstanding intermittent right low back pain, who was involved in a motor vehicle accident with no specific injury at that time.

radiology, emg, nerve conduction study, radiculopathy, peripheral neuropathy, nerve root irritation, motor vehicle accident, lumbosacral paraspinal muscles, spinal epidural, lumbosacral spine, peroneus longus, gastrocnemius medialis, lower extremities, emg/nerve, conduction, needle

The situation involves a medical assessment of a patient with chronic and worsening symptoms, potentially linked to a past vehicle accident. The findings indicate possible nerve root irritation and radiculopathy, with implications for treatment options like epidural injections or surgery. While the patient's quality of life could be significantly impacted if the condition worsens, it is not immediately life-threatening. However, the discussion of surgical intervention does introduce higher stakes due to the risks and implications of surgery, though it is not the only option being considered at this time.


Medical Specialty: Surgery
Sample Name: Delivery Note

HISTORY: , This patient with prenatal care in my office who did have some preterm labor and was treated with nifedipine and was stable on nifedipine and bed rest; unfortunately, felt decreased fetal movement yesterday, 12/29/08, presented to the hospital for evaluation on the evening of 12/29/08.  At approximately 2030 hours and on admission, no cardiac activity was noted by my on-call partner, Dr. X.  This was confirmed by Dr. Y with ultrasound and the patient was admitted with a diagnosis of intrauterine fetal demise at 36 weeks' gestation.,SUMMARY:,  She was admitted.  She was 3 cm dilated on admission.  She desired induction of labor.  Therefore, Pitocin was started.  Epidural was placed for labor pain.  She did have a temperature of 100.7 and antibiotics were ordered including gentamicin and clindamycin secondary to penicillin allergy.  She remained febrile, approximately 100.3.  She then progressed.  On my initial exam at approximately 0730 hours, she was 3 to 4 cm dilated.  She had reported previously some mucous discharge with no ruptured membranes.  Upon my exam, no membranes were noted.  Attempted artificial rupture of membranes was performed.  No fluid noted and there was no fluid discharge noted all the way until the time of delivery.  Intrauterine pressure catheter was placed at that time to document there are adequate pressures on contraction secondary to induction of labor.  She progressed well and completely dilated, pushed approximately three times, and proceeded with delivery.,DELIVERY NOTE:,  Delivery is a normal spontaneous vaginal delivery of an intrauterine fetal demise.  Fetal position is right occiput anterior.,COMPLICATIONS: , Again, intrauterine fetal demise.  Placenta delivery spontaneous.  Condition was intact with a three-vessel cord.  Lacerations; she had a small right periurethral laceration as well as a small second-degree midline laceration.  These were both repaired postdelivery with 4-0 Vicryl on an SH and a 3-0 Vicryl on a CT-1 respectively.  Estimated blood loss was 200 mL.,Infant is a male infant, appears grossly morphologically normal.  Apgars were 0 and 0.  Weight pending at this time.,NARRATIVE OF DELIVERY:,  I was called.  This patient was completely dilated.  I arrived.  She pushed for three contractions.  She was very comfortable.  She delivered the fetal vertex in the right occiput anterior position followed by the remainder of the infant.  There was a tight nuchal cord x1 that was reduced after delivery of the fetus.  Cord was doubly clamped.  The infant was transferred to a bassinet cleaned by the nursing staff en route.  The placenta delivered spontaneously, was carefully examined, found to be intact.  No signs of abruption.  No signs of abnormal placentation or abnormal cord insertion.  The cord was examined and a three-vessel cord was confirmed.  At this time, IV Pitocin and bimanual massage.  Fundus firm as above with minimal postpartum bleeding.  The vagina and perineum were carefully inspected.  A small right periurethral laceration was noted, was repaired with a 4-0 Vicryl on an SH needle followed by a small second-degree midline laceration, was repaired in a normal running fashion with a 3-0 Vicryl suture.  At this time, the repair is intact.  She is hemostatic.  All instruments and sponges were removed from the vagina and the procedure was ended.,Father of the baby has seen the baby at this time and the mother is waiting to hold the baby at this time.  We have called pastor in to baptize the baby as well as calling social work.  They are deciding on a burial versus cremation, have decided against autopsy at this time.  She will be transferred to postpartum for her recovery.  She will be continued on antibiotics secondary to fever to eliminate endometritis and hopefully will be discharged home tomorrow morning.,All of the care and findings were discussed in detail with Christine and Bryan and at this time obviously they are very upset and grieving, but grieving appropriately and understanding the findings and the fact that there is not always a known cause for a term fetal demise.  I have discussed with her that we will do some blood workup postdelivery for infectious disease profile and clotting disorders.
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DESCRIPTION: Delivery is a normal spontaneous vaginal delivery of an intrauterine fetal demise.  Fetal position is right occiput anterior.

surgery, decreased fetal movement, labor pain, preterm labor, delivery note, vaginal delivery, fetal position, fetal demise, intrauterine, delivery, spontaneous, dilated, lacerations, cord, fetal

The situation involves the delivery of a stillborn infant, which is an emotionally sensitive and deeply impactful event for the patient's family. The document outlines the clinical process of delivery and the emotional and logistical considerations following the intrauterine fetal demise. Such scenarios are considered high-stakes due to the emotional and psychological impact on the family, as well as the medical care considerations for the mother following the difficult delivery.


Medical Specialty: Surgery
Sample Name: Anterior Cervical Discectomy - 3

PREOPERATIVE DIAGNOSES: , Cervical disk protrusions at C5-C6 and C6-C7, cervical radiculopathy, and cervical pain.,POSTOPERATIVE DIAGNOSES:,  Cervical disk protrusions at C5-C6 and C6-C7, cervical radiculopathy, and cervical pain.,PROCEDURES:,  C5-C6 and C6-C7 anterior cervical discectomy (two levels) C5-C6 and C6-C7 allograft fusions.  A C5-C7 anterior cervical plate fixation (Sofamor Danek titanium window plate) intraoperative fluoroscopy used and intraoperative microscopy used.  Intraoperative SSEP and EMG monitoring used.,ANESTHESIA: , General endotracheal.,COMPLICATIONS:,  None.,INDICATION FOR THE PROCEDURE: , This lady presented with history of cervical pain associated with cervical radiculopathy with cervical and left arm pain, numbness, weakness, with MRI showing significant disk protrusions with the associate complexes at C5-C6 and C6-C7 with associated cervical radiculopathy.  After failure of conservative treatment, this patient elected to undergo surgery.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the OR and after adequate general endotracheal anesthesia, she was placed supine on the OR table with the head of the bed about 10 degrees.  A shoulder roll was placed and the head supported on a donut support.  The cervical region was prepped and draped in the standard fashion.  A transverse cervical incision was made from the midline, which was lateral to the medial edge of the sternocleidomastoid two fingerbreadths above the right clavicle.  In a transverse fashion, the incision was taken down through the skin and subcutaneous tissue and through the platysmata and a subplatysmal dissection done.  Then, the dissection continued medial to the sternocleidomastoid muscle and then medial to the carotid artery to the prevertebral fascia, which was gently dissected and released superiorly and inferiorly.  Spinal needles were placed into the displaced C5-C6 and C6-C7 to confirm these disk levels using lateral fluoroscopy.  Following this, monopolar coagulation was used to dissect the medial edge of the longus colli muscles off the adjacent vertebrae between C5-C7 and then the Trimline retractors were placed to retract the longus colli muscles laterally and blunt retractors were placed superiorly and inferiorly.  A #15 scalpel was used to do a discectomy at C5-C6 from endplate-to-endplate and uncovertebral joint.  On the uncovertebral joint, a pituitary rongeur was used to empty out any disk material ____________ to further remove the disk material down to the posterior aspect.  This was done under the microscope.  A high-speed drill under the microscope was used to drill down the endplates to the posterior aspect of the annulus.  A blunt trocar was passed underneath the posterior longitudinal ligament and it was gently released using the #15 scalpel and then Kerrison punches 1-mm and then 2-mm were used to decompress further disk calcified material at the C5-C6 level.  This was done bilaterally to allow good decompression of the thecal sac and adjacent neuroforamen.  Then, at the C6-C7 level, in a similar fashion, #15 blade was used to do a discectomy from uncovertebral joint to uncovertebral joint and from endplate-to-endplate using a #15 scalpel to enter the disk space and then the curette was then used to remove the disk calcified material in the endplate, and then high-speed drill under the microscope was used to drill down the disk space down to the posterior aspect of the annulus where a blunt trocar was passed underneath the posterior longitudinal ligament which was gently released.  Then using the Kerrison punches, we used 1-mm and 2-mm, to remove disk calcified material, which was extending more posteriorly to the left and the right.  This was gently removed and decompressed to allow good decompression of the thecal sac and adjacent nerve roots.  With this done, the wound was irrigated.  Hemostasis was ensured with bipolar coagulation.  Vertebral body distraction pins were then placed to the vertebral body of C5 and C7 for vertebral distraction and then a 6-mm allograft performed grafts were taken and packed in either aspect with demineralized bone matrix and this was tapped in flush with the vertebral bodies above and below C5-C6 and C6-C7 discectomy sites.  Then, the vertebral body distraction pins were gently removed to allow for graft seating and compression and then the anterior cervical plate (Danek windows titanium plates) was then taken and sized and placed.  A temporary pin was initially used to align the plate and then keeping the position and then two screw holes were drilled in the vertebral body of C5, two in the vertebral body of C6, and two in the vertebral body of C7.  The holes were then drilled and after this self-tapping screws were placed into the vertebral body of C5, C6, and C7 across the plate to allow the plate to fit and stay flush with the vertebral body between C5, C6, and C7.  With this done, operative fluoroscopy was used to check good alignment of the graft, screw, and plate, and then the wound was irrigated.  Hemostasis was ensured with bipolar coagulation and then the locking screws were tightened down.  A #10 round Jackson-Pratt drain was placed into the prevertebral space and brought out from a separate stab wound skin incision site.  Then, the platysma was approximated using 2-0 Vicryl inverted interrupted stitches and the skin closed with 4-0 Vicryl running subcuticular stitch.  Steri-Strips and sterile dressings were applied.  The patient remained hemodynamically stable throughout the procedure.  Throughout the procedure, the microscope had been used for the disk decompression and high-speed drilling.  In addition, intraoperative SSEP, EMG monitoring, and motor-evoked potentials remained stable throughout the procedure.  The patient remained stable throughout the procedure.
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DESCRIPTION: Anterior cervical discectomy (two levels) and C5-C6 and C6-C7 allograft fusions.  A C5-C7 anterior cervical plate fixation (Sofamor Danek titanium window plate) intraoperative fluoroscopy used and intraoperative microscopy used.  Intraoperative SSEP and EMG monitoring used.

surgery, cervical disk protrusions, cervical radiculopathy, cervical pain, cervical plate fixation, sofamor danek titanium window plate, anterior cervical discectomy, vertebral body, vertebral, disk, intraoperative, anterior, decompression, fluoroscopy, radiculopathy, discectomy, cervical,

The procedure described is an anterior cervical discectomy and fusion, a complex and delicate surgical intervention involving the cervical spine. This type of surgery addresses significant health issues like disk protrusions and radiculopathy, which can cause severe pain and neurological symptoms. The use of general anesthesia, complex surgical techniques, and monitoring like SSEP and EMG indicates major surgery with potential risks, such as nerve damage, infection, or complications associated with spinal surgery. While this is a routine procedure for experienced surgeons, any spinal surgery carries inherent risks, making it a high-stakes situation.


Medical Specialty: Surgery
Sample Name: Coarctation of Aorta

HISTORY: , The patient is a 4-month-old who presented with respiratory distress and absent femoral pulses with subsequent evaluation including echocardiogram that demonstrated severe coarctation of the aorta with a peak gradient of 29 mmHg and associated dilated cardiomyopathy with fractional shortening of 16%.  A bicuspid aortic valve was also seen without insufficiency or stenosis.  The patient underwent cardiac catheterization for balloon angioplasty for coarctation of the aorta.,PROCEDURE:  ,After sedation and general endotracheal anesthesia, the patient was prepped and draped.  Cardiac catheterization was performed as outlined in the attached continuation sheets.  Vascular entry was by percutaneous technique, and the patient was heparinized.  Monitoring during the procedure included continuous surface ECG, continuous pulse oximetry, and cycled cuff blood pressures, in addition to intravascular pressures.,Using a percutaneous technique a 4-French 8 cm long double lumen central venous catheter was inserted in the left femoral vein and sutured into place.  There was good blood return from both the ports.,Using a 4-French sheath a 4-French wedge catheter was inserted into the right femoral vein and advanced through the right heart structures out to the branch of pulmonary arteries.  The atrial septum was not probe patent.,Using a 4-French sheath a 4-French marker pigtail catheter was inserted into the left femoral artery and advanced retrograde to the descending aorta ,ascending aorta and left ventricle.  A descending aortogram demonstrated discrete coarctation of the aorta approximately 8 mm distal to the origin of the left subclavian artery.  The transverse arch measured 5 mm.  Isthmus measured 4.7 mm and coarctation measured 2.9 x 1.8 mm at the descending aorta level.  The diaphragm measured 5.6 mm.  The pigtail catheter was exchanged for a wedge catheter, which was then directed into the right innominate artery.  This catheter was exchanged over a wire for a Tyshak mini 6 x 2 cm balloon catheter which was advanced across the coarctation and inflated with complete disappearance of discrete waist.  Pressure pull-back following angioplasty, however, demonstrated a residual of 15-20 mmHg gradient.  Repeat angiogram showed mild improvement in degree of aortic narrowing.  The angioplasty was then performed using a Tyshak mini 7 x 2 cm balloon catheter with complete disappearance of mild waist.  The pigtail catheter was then reintroduced for a pressure pull-back measurement and final angiogram.,Flows were calculated by the Fick technique using an assumed oxygen consumption.,Cineangiograms were obtained with injection in the descending aorta.,After angiography, two normal-appearing renal collecting systems were visualized.  The catheters and sheaths were removed and topical pressure applied for hemostasis.  The patient was returned to the pediatric intensive care unit in satisfactory condition.  There were no complications.,DISCUSSION: , Oxygen consumption was assumed to be normal.  Mixed venous saturation was low due to mild systemic arterial desaturation and anemia.  There is no evidence of significant intracardiac shunt.  Further the heart was desaturated due to VQ mismatch.,Phasic right-sided pressures were normal as was the right pulmonary artery capillary wedge pressure with the A-wave similar to the normal left ventricular end-diastolic pressure of 12 mmHg.  Left ventricular systolic pressure was mildly increased with a 60 mmHg systolic gradient into the ascending aorta and a 29 mmHg systolic gradient on pressure pull-back to the descending aorta.  The calculated flows were mildly increased.  Vascular resistances were normal.  A cineangiogram with contrast injection in the descending aorta showed a normal left aortic arch with normal origins of the brachiocephalic vessels.  There is discrete juxtaductal coarctation of the aorta.  Flow within the intercostal arteries was retrograde.  Following balloon angioplasty of coarctation of the aorta, there was slight fall in the mixed venous saturation and an increase in systemic arterial saturation as the fall in left ventricular systolic pressure from 99 mmHg to 92 mmHg.  There remained a 4 mmHg systolic gradient into the ascending aorta and 9 mmHg systolic gradient pressure pull-back to the descending aorta.  The calculated systemic flow fell to normal values.  Final angiogram with injection in the descending aorta demonstrated improved caliber of coarctation of the aorta with mild intimal irregularity and a small left lateral filling defect consistent with a small intimal tear in the region of the ductus arteriosus.  There is brisk flow in the descending aorta and appropriate flow in the intercostal arteries.  The narrowest diameter of the aorta measured 4.9 x 4.2 mm.,DIAGNOSES:  ,1.  Juxtaductal coarctation of the aorta.,2.  Dilated cardiomyopathy.,3.  Bicuspid aortic valve.,4.  Patent foramen ovale.,INTERVENTION: , Balloon dilation of coarctation of the aorta.,MANAGEMENT: , The case will be discussed at combined Cardiology and Cardiothoracic Surgery Case Conference.  The patient will be allowed to recover from the current intervention with the hopes of complete left ventricular function recovery.  The patient will undoubtedly require formal coarctation of the aorta repair surgically in 4-6 months.  The further cardiologic care will be directed by Dr. X.
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DESCRIPTION: Juxtaductal coarctation of the aorta, dilated cardiomyopathy, bicuspid aortic valve, patent foramen ovale.

surgery, coarctation, juxtaductal, dilated cardiomyopathy, bicuspid aortic valve, patent foramen ovale, catheter was inserted, mmhg systolic gradient, mmhg systolic, systolic gradient, descending aorta, catheterization, mmhg, ventricular, aorta, aortic, foramen,

The situation involves a 4-month-old infant diagnosed with severe cardiovascular issues, including coarctation of the aorta and dilated cardiomyopathy. The patient underwent a procedure for balloon angioplasty, and although the procedure was successful to a degree, the patient is expected to require additional surgery in the future. Such conditions and procedures for an infant are high-stakes due to the potential for severe complications or even mortality, the critical nature of the infrant's cardiovascular function, and the complexity involved in managing such young patients post-surgery and planning for further interventions.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Cardiology - Letter

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

cardiovascular / pulmonary, capsure, cardiac event, ultrasound, carotid angioplasty, stent placement, letter, angioplastyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

The situation involves a follow-up of a medical procedure (left carotid angioplasty and stent placement), which has significant implications for the patient's health. The outcome of such follow-ups can indicate whether the patient is at risk for future complications. Although the follow-up indicates the patient is doing well with no evidence of significant recurrence, any follow-up related to a serious cardiovascular procedure is high-stakes due to the potential life-threatening nature of complications. However, the letter reports positive findings, reducing the immediacy of the high-stakes nature.


Medical Specialty: IME-QME-Work Comp etc.
Sample Name: Burn - Consult

CHIEF COMPLAINT: , Burn, right arm.,HISTORY OF PRESENT ILLNESS: , This is a Workers' Compensation injury.  This patient, a 41 year-old male, was at a coffee shop, where he works as a cook, and hot oil splashed onto his arm, burning from the elbow to the wrist on the medial aspect.  He has had it cooled, and presents with his friend to the Emergency Department for care.,PAST MEDICAL HISTORY:  ,Noncontributory.,MEDICATIONS:  ,None.,ALLERGIES:  ,None.,PHYSICAL EXAMINATION: , GENERAL:  Well-developed, well-nourished 21-year-old male adult who is appropriate and cooperative.  His only injury is to the right upper extremity.  There are first and second degree burns on the right forearm, ranging from the elbow to the wrist.  Second degree areas with blistering are scattered through the medial aspect of the forearm.  There is no circumferential burn, and I see no areas of deeper burn.  The patient moves his hands well.  Pulses are good.  Circulation to the hand is fine.,FINAL DIAGNOSIS:,1.  First-degree and second-degree burns, right arm secondary to hot oil spill.,2.  Workers' Compensation industrial injury.,TREATMENT: , The wound is cooled and cleansed with soaking in antiseptic solution.  The patient was ordered Demerol 50 mg IM for pain, but he refused and did not want pain medication.  A burn dressing is applied with Neosporin ointment.  The patient is given Tylenol No. 3, tabs #4, to take home with him and take one or two every four hours p.r.n. for pain.  He is to return tomorrow for a dressing change.  Tetanus immunization is up to date.  Preprinted instructions are given.  Workers' Compensation first report and work status report are completed.,DISPOSITION: , Home.
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DESCRIPTION: First-degree and second-degree burns, right arm secondary to hot oil spill - Workers' Compensation industrial injury.

ime-qme-work comp etc., burn, workers' compensation industrial injury, workers' compensation, degree

The situation involves a 41-year-old male who sustained first and second-degree burns on his right arm due to a work-related incident involving hot oil. While burns can be serious, the assessment indicates that there are no third-degree burns or deeper injuries, and circulation is adequate. The patient's condition was managed with standard treatment protocols, and he was discharged to home care with instructions for follow-up. This does not present an immediate life-threatening condition and is managed as a non-emergency work injury. However, it does involve Workers' Compensation, which can have implications for the patient’s employment and financial situation, thus adding some complexity to the stakes. Considering these aspects, the situation can be classified as moderately high-stakes mainly due to its potential impact on the patient's work and economic implications rather than the immediate medical condition.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: ORIF Facial Fractures - Followup

Mr. ABC was transferred to room 123 this afternoon.  We discussed this with the nurses, and it was of course cleared by Dr. X.  The patient is now on his third postoperative day for an open reduction and internal fixation for two facial fractures, as well as open reduction nasal fracture.  He is on his eighth hospital day.,The patient had nasal packing in place, which was removed this evening.  This will make it much easier for him to swallow.  This will facilitate p.o. fluids and IMF diet.,Examination of the face revealed some decreased swelling today.  He had good occlusion with intact intermaxillary fixation.,His tracheotomy tube is in place.  It is a size 8 Shiley nonfenestrated.  He is being suctioned comfortably.,The patient is in need of something for sleep in the evening, so we have recommended Halcion 5 mg at bedtime and repeat of 5 mg in 1 hour if needed.,Tomorrow, we will go ahead and change his trach to a noncuffed or a fenestrated tube, so he may communicate and again this will facilitate his swallowing.  Hopefully, we can decannulate the tracheotomy tube in the next few days.,Overall, I believe this patient is doing well, and we will look forward to being able to transfer him to the prison infirmary.
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DESCRIPTION: The patient is now on his third postoperative day for an open reduction and internal fixation for two facial fractures, as well as open reduction nasal fracture.  He is on his eighth hospital day.

soap / chart / progress notes, fenestrated tube, nasal fracture, facial fractures, orif, tracheotomy, tube, fractures,

The situation involves a postoperative patient following surgical repair of facial and nasal fractures. While the patient is stable and recovering, the presence of a tracheotomy tube, the need for careful monitoring of fluid intake, and evaluation for potential tracheostomy tube changes indicate that the situation requires attentive medical care. The patient's progression and recovery have high importance, but the description does not suggest an immediate life-threatening situation, hence not extremely high-stakes.


Medical Specialty: Surgery
Sample Name: Inguinal Herniorrhaphy - 3

PREOPERATIVE DIAGNOSIS:,  Left inguinal hernia.,POSTOPERATIVE DIAGNOSIS: , Left inguinal hernia, direct.,PROCEDURE: , Left inguinal herniorrhaphy, modified Bassini.,DESCRIPTION OF PROCEDURE:  ,The patient was electively taken to the operating room.  In same day surgery, Dr. X applied a magnet to the pacemaker defibrillator that the patient has to change it into a fixed mode and to protect the device from the action of the cautery.  Informed consent was obtained, and the patient was transferred to the operating room where a time-out process was followed and the patient under general endotracheal anesthesia was prepped and draped in the usual fashion.  Local anesthesia was used as a field block and then an incision was made in the left inguinal area and carried down to the external oblique aponeurosis, which was opened.  The cord was isolated and protected.  It was dissected out.  The lipoma of the cord was removed and the sac was high ligated.  The main hernia was a direct hernia due to weakness of the floor.  A Bassini repair was performed.  We used a number of interrupted sutures of 2-0 Tevdek __________ in the conjoint tendon and the ilioinguinal ligament.,The external oblique muscle was approximated same as the soft tissue with Vicryl and then the skin was closed with subcuticular suture of Monocryl.  The dressing was applied and the patient tolerated the procedure well, estimated blood loss was minimal, was transferred to recovery room in satisfactory condition.
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DESCRIPTION: Left inguinal herniorrhaphy, modified Bassini.  Left inguinal hernia, direct.

surgery, inguinal herniorrhaphy, modified bassini, herniorrhaphy modified bassini, hernia direct, inguinal hernia, inguinal, bassini,

The described procedure is a routine surgical operation for repairing an inguinal hernia, specifically a left inguinal hernia using a modified Bassini technique. Although surgeries always have certain risks such as bleeding, infection, or complications related to anesthesia, this procedure is considered relatively common and straightforward, especially since the patient is reported to have tolerated the procedure well with minimal blood loss and was transferred to recovery in satisfactory condition. Hence, it is not considered high-stakes, though it remains significant in terms of patient health and safety.


Medical Specialty: Pain Management
Sample Name: Radiofrequency Thermocoagulation - 3

PREOPERATIVE DIAGNOSIS:,  Cervical spondylosis.,POSTOPERATIVE DIAGNOSIS:,  Cervical spondylosis.,OPERATION PERFORMED:,  Radiofrequency thermocoagulation (RFTC), medial branch posterior sensory rami of cervical at ***.,SURGEON:,  Ralph Menard, M.D.,ANESTHESIA:,  Local and IV.,COMPLICATIONS:,  None.,DESCRIPTION OF PROCEDURE: , After proper consent was obtained, the patient was taken to the fluoroscopy suite and placed on a fluoroscopy table in a prone position with a chest roll in place.  The neck was placed in a flexed position.  The patient was monitored with blood pressure cuff, EKG, and pulse oximetry and given oxygen via nasal cannula.  The patient was lightly sedated.  The skin was prepped and draped in a sterile classical fashion.,Under fluoroscopy control, the waists of the articular pillars were identified and marked.  Local anesthesia infiltrated subcutaneously and deep extending down toward these previously marked points.  Once the anesthesia was established, an insulated 10-cm, 22-gauge needle with a 5-mm non-insulated stimulating tip was placed in contact with the waists of the articular pillars at the affected levels that were previously mentioned.  This was done under direct fluoroscopic control utilizing a gun barrel technique with PA views initially for orientation and then a lateral view to determine the depth of the needle.  For C3 to C6 medial branch RFTC's, the needles are placed along the ventral aspect of a line that connects the greatest antero-posterior diameter of the articular pillar but remains dorsal to the foramen as seen on lateral imaging.  For a C7 medial branch RFTC, the needle tip is positioned more superiorly such that it overlies the superior articular process.  For a C8 medial branch RFTC, the needle is placed at the junction of the superior articulating facet and the base of the transverse process of T1.,Sensory stimulation was carried out at 50 Hz from 0 to 2.0 volts.  Stimulation was stopped once the maximum voltage was delivered or the patient either described a buzzing sensation indicating that it was a nonpainful nerve, or it caused replication of their concordant pain.  The stimulation was then changed to 2 Hz for motor stimulation and advanced up to 2.0 volts or until motor stimulation was found at that level.  If motor stimulation occurred, the needle was repositioned to abolish it but still cause concordant pain, or the RFTC was aborted at this level.,If the sensory stimulation caused concordant pain without motor stimulation, the area was then anesthetized with 1 cc of Marcaine 0.5% with 5 mg of methyl prednisolone acetate.  Once the anesthesia was established, a radiofrequency lesioning was then done at 65 degrees for 60 seconds.  The same procedure was carried out at all the affected levels.  The patient tolerated the procedure well without any difficulties or complications.
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DESCRIPTION: Cervical spondylosis.  Radiofrequency thermocoagulation (RFTC), medial branch posterior sensory rami.

pain management, rami, fluoroscopic control, radiofrequency thermocoagulation, cervical spondylosis, articular pillars, motor stimulation, medial branch, thermocoagulation, rftc, needle, cervical, stimulation

The procedure described involves Radiofrequency Thermocoagulation, a minimally invasive technique used in pain management for conditions like cervical spondylosis. While it's a specialized procedure requiring precise needle placement and careful monitoring, it is not as critical as major surgeries that involve life-threatening conditions. Key complications were not present in this case, and the procedure was conducted successfully. Thus, while it requires skill and accuracy, the stakes are moderate, given it is a routine part of some pain management practices.


Medical Specialty: Surgery
Sample Name: Cineangiography - 1

REASON FOR CATHETERIZATION:,  ST-elevation myocardial infarction.,PROCEDURES UNDERTAKEN,1.  Left coronary system cineangiography.,2.  Right coronary system cineangiography.,3.  Left ventriculogram.,4.  PCI to the left circumflex with a 3.5 x 12 and a 3.5 x 8 mm Vision bare-metal stents postdilated with a 3.75-mm noncompliant balloon x2.,PROCEDURE: , After all risks and benefits were explained to the patient, informed consent was obtained.  The patient was brought to the cardiac cath suite.  Right groin was prepped in usual sterile fashion.  Right common femoral artery was cannulated with the modified Seldinger technique.  A 6-French sheath was introduced.  Next, Judkins right catheter was used to engage the right coronary artery and cineangiography was recorded in multiple views.  Next, an EBU 3.5 guide was used to engage the left coronary system.  Cineangiography was recorded in several views and it was noted to have a 99% proximal left circumflex stenosis.  Angiomax bolus and drip were started after checking an ACT, which was 180, and an Universal wire was advanced through the left circumflex beyond the lesion.  Next, a 3.0 x 12 mm balloon was used to pre-dilate the lesion.  Next a 3.5 x 12 mm Vision bare-metal stent was advanced to the area of stenosis and deployed at 12 atmospheres.  There was noted to be a plaque shift proximally at the edge of the stent.  Therefore, a 3.5 x 8 mm Vision bare-metal stent was advanced to cover the proximal margin of the first stent and deployed at 12 atmospheres.  Next, a 3.75 x 13 mm noncompliant balloon was advanced into the margin of the stent and two inflations at 20 atmospheres were done for 20 seconds.  Final images showed excellent results with initial 99% stenosis reduced to 0%.  The patient continues to have residual stenosis in the mid to distal in the OM branch.  At this point, wire was removed.  Final images confirmed initial stent results, no evidence of dissection, perforation, or complications.,Next, an angled pigtail catheter was advanced into the left ventricular cavity.  LV pressure was measured.  LV gram was done in both the LAO and RAO projections and a pullback gradient across the aortic valve was done and recorded.  Finally, all guides were removed.  Right femoral artery access site was imaged and Angio-Seal deployed to attain excellent hemostasis.  The patient tolerated the procedure very well without complications.,DIAGNOSTIC FINDINGS,1.  Left main:  Left main is a large-caliber vessel bifurcating in LAD and left circumflex with no significant disease.,2.  The LAD:  LAD is a large-caliber vessel, wraps around the apex, gives off multiple septal perforators, three small-to-medium caliber diagonal branches without any significant disease.,3.  Left circumflex:  Left circumflex is a large-caliber vessel, gives off a large distal PDA branch, has a 99% proximal lesion, 50% mid vessel lesion, and a 50% lesion in the OM, which is a distal branch.,4.  Right coronary artery:  Right coronary artery is a moderate-caliber vessel, dominant, bifurcates into PDA and PLV branches, has only mild disease.  Otherwise, no significant stenosis noted.,5.  LV:  The LVEF 50%.  Inferolateral wall hypokinesis.  No significant mitral regurgitation.  No gradient across the aortic valve on pullback.,ASSESSMENT AND PLAN: , ST-elevation myocardial infarction with a 99% stenosis of the proximal portion of the left circumflex treated with a 3.5 x 12 mm Vision bare-metal stent and a 3.5 x 8 mm Vision bare-metal stent.  Excellent results, 0% residual stenosis.  The patient continues to have some residual 50% stenosis in the left circumflex system, some mild disease throughout the other vessels.  Therefore, we will aggressively treat this patient medically with close followup as an outpatient.
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DESCRIPTION: Left and right coronary system cineangiography.  Left ventriculogram.  PCI to the left circumflex with a 3.5 x 12 and a 3.5 x 8 mm Vision bare-metal stents postdilated with a 3.75-mm noncompliant balloon x2.

surgery, ventriculogram, circumflex, bare-metal stents, myocardial infarction, st-elevation, coronary system cineangiography, infarction, stents, cineangiography, stenosis,

The situation involves a patient undergoing a percutaneous coronary intervention (PCI) for a significant coronary artery blockage, which is a critical procedure typically performed in the context of a serious cardiac event, specifically a ST-elevation myocardial infarction (STEMI). While the procedure has been completed successfully with no complications, the stakes remain high due to the potential for future cardiac events and the requirement for ongoing medical management of residual stenosis and other mild disease. Cardiac procedures of this nature are fundamentally high-stakes given the potential for life-threatening complications if not managed properly.


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

Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Consult - Abnormal EKG

REASON FOR CONSULTATION: , Abnormal EKG and rapid heart rate.,HISTORY OF PRESENT ILLNESS: , The patient is an 86-year-old female.  From the last few days, she is not feeling well, fatigue, tiredness, weakness, nausea, no vomiting, no hematemesis or melena.  The patient relates to have some low-grade fever.  The patient came to the emergency room.  Initially showed atrial fibrillation with rapid ventricular response.  It appears that the patient has chronic atrial fibrillation.  As per the medications, they are not very clear.  Husband has gone out to brief her medications.  She denies any specific chest pain.  Her main complaint is shortness of breath and symptoms as above.,CORONARY RISK FACTORS: , No hypertension or diabetes mellitus.  Nonsmoker.  Cholesterol status is normal.  Questionable history of coronary artery disease.  Family history noncontributory.,FAMILY HISTORY:,  Nonsignificant.,PAST SURGICAL HISTORY: , Questionable coronary artery bypass surgery versus valve replacement.,MEDICATIONS: , Unclear at this time, but she does take Coumadin.,ALLERGIES: , ASPIRIN.,PERSONAL HISTORY: , She is married, nonsmoker.  Does not consume alcohol.  No history of recreational drug use.,PAST MEDICAL HISTORY: , Symptoms as above, atrial fibrillation, history of open heart surgery, possible bypass surgery; however, after further query, husband relates that she may had just a valve surgery.,REVIEW OF SYSTEMS,CONSTITUTIONAL:  Weakness, fatigue, and tiredness.,HEENT:  No history of cataract, history of blurry vision and hearing impairment.,CARDIOVASCULAR:  Irregular heart rhythm with congestive heart failure, questionable coronary artery disease.,RESPIRATORY:  Shortness of breath, questionable pneumonia.  No valley fever.,GASTROINTESTINAL:  No nausea, no vomiting, hematemesis or melena.,UROLOGICAL:  No frequency or urgency.,MUSCULOSKELETAL:  Arthritis, muscle weakness.,CNS:  No TIA.  No CVA.  No seizure disorder.,SKIN:  Nonsignificant.,PSYCHOLOGIC:  Anxiety and depression.,ALLERGIES:  Nonsignificant except as mentioned above for medications.,PHYSICAL EXAMINATION,VITAL SIGNS:  Pulse of 122, blood pressure 148/78, afebrile, and respiratory rate 18 per minute.,HEENT AND NECK:  Neck is supple.  Atraumatic and normocephalic.  Neck veins are flat.  No thyromegaly.,LUNGS:  Air entry bilaterally fair.  Decreased breath sounds especially in the right basilar areas.  Few crackles.,HEART:  Normal S1 and S2, irregular.,ABDOMEN:  Soft and nontender.,EXTREMITIES:  No edema.  Pulse is palpable.  No clubbing or cyanosis.,CNS:  Grossly intact.,MUSCULOSKELETAL:  Arthritic changes.,PSYCHOLOGICAL:  None significant.,DIAGNOSTIC DATA: , EKG, atrial fibrillation with rapid ventricular response, and nonspecific ST-T changes.  INR of 4.5, H and H 10 and 30.  BUN and creatinine are within normal limits.  Chest x-ray confirmed right lower lobe patchy infiltrate, and trace of pneumonia.,IMPRESSION:,1.  The patient is an 86-year-old female who has questionable bypass surgery, questionable valve surgery with a rapid atrial heart rate, chronic atrial fibrillation with rapid ventricular response, exacerbated by most likely underlying pneumonia by chest x-ray findings.,2.  Symptoms as above.,RECOMMENDATIONS:,1.  We will start her on a low dose of beta-blocker for rate control and antibiotic for pneumonia.  Once, if she is stable, we will consider further cardiac workup.,2.  We will also obtain an echocardiogram to assess valves such as whether she had a prior valve surgery versus coronary artery bypass surgery.
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DESCRIPTION: Abnormal EKG and rapid heart rate.  The patient came to the emergency room.  Initially showed atrial fibrillation with rapid ventricular response.  It appears that the patient has chronic atrial fibrillation.  She denies any specific chest pain.  Her main complaint is shortness of breath and symptoms as above.

The provided medical case involves an 86-year-old female patient presenting with abnormal EKG, rapid heart rate, and chronic atrial fibrillation, which are significant cardiovascular concerns. Given her age and symptoms, including shortness of breath and possible pneumonia, the situation is potentially life-threatening if not managed correctly. Additionally, her unclear medication history and potential past surgeries add complexity to her treatment. These factors collectively make the clinical situation high-stakes due to the risks of complications from atrial fibrillation and possible pneumonia.


Medical Specialty: Consult - History and Phy.
Sample Name: Gen Med Consult - 47

HISTORY OF PRESENT ILLNESS: , This is a 76-year-old female that was admitted with fever, chills, and left pelvic pain.  The patient was well visiting in ABC, with her daughter that evening.  She had pain in her left posterior pelvic and low back region.  They came back to XYZ the following day.  By the time they got here, she was in severe pain and had fever.  They came straight to the emergency room.  She was admitted.  She had temperature of 104 degrees F.  It has been spiking ever since and she has had left sacroiliac type hip pain.  Multiple blood studies have been done including cultures, febrile agglutinins, etc.  She has had run a higher blood glucose to the normal and she has been on sliding scale insulin.  She was not known previously to be a diabetic.  All x-rays have not been helpful as far as to determine the etiology of her discomfort.  MRIs of the lumbar spine and the pelvis and both thighs have been unremarkable for any inflammatory process.  She does have degenerative disk disease of her lumbar spine but no hip pathology.  She has swollen inguinal nodes bilaterally.,PAST MEDICAL HISTORY AND REVIEW OF SYSTEMS: , She was not known to be a diabetic until this admission.  She had been hypertensive.  She has been on medications and has been controlled.  She has not had hyperlipidemia.  She has had no thyroid problems.  There has been no asthma, bronchitis, TB, emphysema or pneumonia.  No tuberculosis.  She has had no breast tumors.  She has had no chest pain or cardiac problems.  She has had gallbladder surgery.  She has not had any gastritis or ulcers.  She has had no kidney disease.  She has had a hysterectomy.  She has had 9 pregnancies and 8 living children.  She had A&P repair.  She had a sacral abscess after a spinal.  It sounds to me like she had a pilonidal cyst, which took about 3 operations to heal.  There have been fractures and no significant arthritis.  She has been quite active at her ranch in Mexico.  She raises goats and cattle.  She drives a tractor and in short, has been very active.,PHYSICAL EXAMINATION:,  She is a short female, alert.  She is shivering.  She has ice in her axilla and behind her neck.  She is febrile to 101 degrees F. She is alert.  Her complaint is that of hip pain in the posterior sacroiliac joint area.  She moves both her upper extremities well.  She can move her right leg well.  She actually can move her left hip and knee without much discomfort but the pain radiates from her sacroiliac joint.  She cannot stand, sit or turn without severe pain.  She has normal knee reflexes.  No ankle reflexes.  She has bounding tibial pulses.  No sensory deficit.  She says she knows when she has to void.  She has a healed scar in the upper sacral region.  There is some bruising around the buttocks but the daughter says that is from her being in bed lying on her back.,PLAN: , My plan is to do a triple-phase bone scan.  I am suspecting an infection possibly in the left sacroiliac joint.  It is probably some type of bacterium, the etiology of which is undetermined.  She has had a normal white count despite her fever.  There has been a history of brucellosis in the past, but her titers at this time are negative.  Continue medication which included antibiotics and also the Motrin and Darvocet.,
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DESCRIPTION: The patient had temperature of 104 degrees F.  It has been spiking ever since and she has had left sacroiliac type hip pain.  She does have degenerative disk disease of her lumbar spine but no hip pathology.  She has swollen inguinal nodes bilaterally.

consult - history and phy., inflammatory, degenerative, fever, lumbar spine, sacroiliac joint, inguinal, sacroiliac, hip,

The situation described involves a medical consultation for a 76-year-old female patient with severe symptoms, including high fever and significant pain, indicating a potentially serious infection. The case involves various diagnostic challenges due to complex symptoms and an undetermined infection etiology. Although the patient's life is not immediately under threat, the presence of high fever and severe discomfort, combined with the difficulty in pinpointing the exact cause of illness, creates a situation where timely and accurate diagnosis is critical to prevent potential complications. The possibility of an infection in the sacroiliac joint increases the stakes, making the situation high-stakes from a medical perspective.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Multiple Stent Placements

PROCEDURE PERFORMED:,1.  Left heart catheterization, left ventriculogram, aortogram, coronary angiogram.,2.  PCI of the LAD and left main coronary artery with Impella assist device.,INDICATIONS FOR PROCEDURE: , Unstable angina and congestive heart failure with impaired LV function.,TECHNIQUE OF PROCEDURE: , After obtaining informed consent, the patient was brought to the cardiac catheterization suite in postabsorptive and nonsedated state.  The right groin was prepped and draped in the usual sterile manner.  Lidocaine 2% was used for infiltration anesthesia.  Using modified Seldinger technique, a 7-French sheath was introduced into the right common femoral artery and a 6-French sheath was introduced into the right common femoral vein.  Through the arterial sheath, angiography of the right common femoral artery was obtained.  Thereafter, 6-French pigtail catheter was advanced to the level of the distal aorta where angiography of the distal aorta and the bifurcation of the right and left common iliac arteries was obtained.  Thereafter, a 4-French sheath was introduced into the left common femoral artery using modified Seldinger technique.  Thereafter, the pigtail catheter was advanced over an 0.035-inch J-wire into the left ventricle and LV-gram was performed in RAO view and after pullback, an aortogram was performed in the LAO view.  Therefore, a 6-French JL4 and JR4 guiding catheters were used to engage the left and right coronary arteries respectively and multiple orthogonal views of the coronary arteries were obtained.,ANGIOGRAPHIC FINDINGS:  ,1.  LV-gram:  LVEDP was 15 mmHg.  LV ejection fraction 10% to 15% with global hypokinesis.  Only anterior wall is contracting.  There was no mitral regurgitation.  There was no gradient across the aortic valve upon pullback, and on aortography, there was no evidence of aortic dissection or aortic regurgitation.,2.  The right coronary artery is a dominant vessels with a mid 50% to 70% stenosis which was not treated.  The left main coronary artery calcified vessel with disease.,2.  The left anterior descending artery had an 80% to 90% mid-stenosis.  First diagonal branch had a more than 90% stenosis.,3.  The circumflex coronary artery had a patent stent.,INTERVENTION: , After reviewing the angiographic images, we elected to proceed with intervention of the left anterior descending artery.  The 4-French sheath in the left common femoral artery was upsized to a 12-French Impella sheath through which an Amplatz wire and a 6-French multipurpose catheter were advanced into the left ventricle.  The Amplatz wire was exchanged for an Impella 0.018-inch stiff wire.  The multipurpose catheter was removed, and the Impella was advanced into the left ventricle and a performance level of 8 was achieved with a cardiac output of 2 to 2.5 l/min.  Thereafter, a 7-French JL4 guiding catheter was used to engage the left coronary artery and an Asahi soft 0.014-inch wire was advanced into the left anterior descending artery and a second 0.014-inch Asahi soft wire was advanced into the diagonal branch.  The diagonal branch was predilated with a 2.5 x 30-mm Sprinter balloon at nominal atmospheres and thereafter a 2.5 x 24 Endeavor stent was successfully deployed in the mid-LAD and a 3.0 x 15-mm Endeavor stent was deployed in the proximal LAD.  The stent delivery balloon was used to post-dilate the overlapping segment.  The LAD, the diagonal was rewires with an 0.014-inch Asahi soft wire and a 3.0 x 20-mm Maverick balloon was advanced into the LAD for post-dilatation and a 2.0 x 30-mm Sprinter balloon was advanced into the diagonal for kissing inflations which were performed at nominal atmospheres.  At this point, it was noted that the left main had a retrograde dissection.  A 3.5 x 18-mm Endeavor stent was successfully deployed in the left main coronary artery.  The Asahi soft wire in the diagonal was removed and placed into the circumflex coronary artery.  Kissing inflations of the LAD and the circumflex coronary artery were performed using 3.0 x 20 Maverick balloons x2 balloons, inflated at high atmospheres of 14.,RESULTS: , Lesion reduction in the LAD FROM 90% to 0% and TIMI 3 flow obtained.  Lesion reduction in the diagonal from 90% to less than 60% and TIMI 3 flow obtained.  Lesion reduction in the left maintained coronary artery from 50% to 0% and TIMI 3 flow obtained.,The patient tolerated the procedure well and the inflations well with no evidence of any hemodynamic instability.  The Impella device was gradually decreased from performance level of 8 to performance level of 1 at which point it was removed into the aorta and it was turned off and the Impella was removed from the body and the 2 Perclose sutures were tightened.  From the right common femoral artery, a 6-French IMA catheter was advanced and an 0.035-inch wire down into the left common femoral and superficial femoral artery, over which an 8 x 40 balloon was advanced and tamponade of the arteriotomy site of the left common femoral artery was performed from within the artery at 3 atmospheres for a total of 20 minutes.  The right common femoral artery and vein sheaths were both sutured in place for further observation.  Of note, the patient received Angiomax during the procedure and an ACT above 300 was maintained.,IMPRESSION:,1.  Left ventricular dysfunction with ejection fraction of 10% to 15%.,2.  High complex percutaneous coronary intervention of the left main coronary artery, left anterior descending artery, and diagonal with Impella circulatory support.,COMPLICATIONS: , None.,The patient tolerated the procedure well with no complications.  The estimated blood loss was 200 ml.  Estimated dye used was 200 ml of Visipaque.  The patient remained hemodynamically stable with no hypotension and no hematomas in the groins.,PLAN:  ,1.  Aspirin, Plavix, statins, beta blockers, ACE inhibitors as tolerated.,2.  Hydration.,3.  The patient will be observed over night for any hemodynamic instability or ischemia.  If she remains stable, the right common femoral artery and vein sheaths will be removed and manual pressure will be applied for hemostasis.
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DESCRIPTION: Multiple stent placements with Impella circulatory assist device.

cardiovascular / pulmonary, impella circulatory assist device, impella assist device, unstable angina, congestive heart failure, heart catheterization, ventriculogram, aortogram, angiogram, ventricular dysfunction, pigtail catheter was advanced, femoral artery and vein, artery and vein, asahi soft wire, circumflex coronary artery, common femoral artery, modified seldinger technique, multiple stent placements, timi flow, multiple stent, impella circulatory, french sheath, femoral artery, endeavor stent, descending artery, coronary artery, common femoral, asahi soft, anterior descending, femoral, coronary, artery, impella, catheterization,

The scenario described involves a highly complex cardiovascular procedure involving multiple stent placements and the use of an Impella device for circulatory support. The patient is undergoing treatment for unstable angina and congestive heart failure with impaired LV function, conditions that are inherently high-risk. The need for a device like the Impella indicates that the patient's heart is unable to maintain sufficient blood flow on its own, underscoring the severity of the situation. Additionally, the placement of multiple stents and dealing with potential complications, such as a retrograde dissection of the left main artery during the procedure, highlight the critical stakes involved in ensuring patient safety and successful intervention. This type of procedure requires expert management and carries significant risks, including potential for severe complications if not managed appropriately.


Medical Specialty: Surgery
Sample Name: Dental Prophylaxis

OPERATION PERFORMED:  ,Dental prophylaxis under general anesthesia.,PREOPERATIVE DIAGNOSES:,1.  Impacted wisdom teeth.,2.  Moderate gingivitis.,POSTOPERATIVE DIAGNOSES:,1.  Impacted wisdom teeth.,2.  Moderate gingivitis.,COMPLICATIONS:  ,None.,ESTIMATED BLOOD LOSS:  ,Minimal.,DURATION OF SURGERY:  ,One hour 17 minutes.,BRIEF HISTORY:  ,The patient was referred to me by Dr. X.  He contacted myself and stated that Angelica was going to have her wisdom teeth extracted in the setting of a hospital operating room at Hospital and he inquired if we could pair on the procedure and I could do her full mouth dental rehabilitation before the wisdom teeth were removed by him.  I agreed.  I saw her in my office and she was cooperative for full mouth set of radiographs in my office and a clinical examination.  This clinical and radiographic examination revealed no dental caries; however, she was in need of a good dental cleaning.,OPERATIVE PREPARATION:  ,The patient was brought to Hospital Day Surgery accompanied by her mother.  I met with them and discussed the needs of the child, types of restoration to be performed, and the risks and benefits of the treatment as well as the options and alternatives of the treatment.  After all their questions and concerns were addressed, they gave their informed consent to proceed with the treatment.  The patient's history and physical examination was reviewed.  Once she was cleared by Anesthesia, she was taken back to the operating room.,OPERATIVE PROCEDURE:  ,The patient was placed on the surgical table in the usual supine position with all extremities protected.  Anesthesia was induced by mask.  The patient was then intubated with a nasal endotracheal tube and the tube was stabilized.  The head was wrapped and the eyes were taped shut for protection.  An Angiocath was previously placed in preop.  The head and neck were draped in sterile towels, and the body was covered with lead apron and sterile sheath.  A moist continuous throat pack was placed beyond tonsillar pillars.  Plastic lip and cheek retractors were then placed.  Preoperative digital intraoral photographs were taken.  No digital radiographs were taken in the operating room, as I stated before I had a full set of digital radiographs taken in my office.  A prophylaxis was then performed using a Prophy cup and fluoridated Prophy paste after scaling and replaning was done.  She presented with moderate calculus on the buccal surfaces of her maxillary, first molars and lower molars.  She did not require any restorative dentistry.,Upon the conclusion of the restorative phase, the oral cavity was aspirated and found to be free of blood, mucus, and other debris.  The original treatment plan was verified with the actual treatment provided.  Postoperative clinical photographs were taken.  The continuous gauze throat pack was removed with continuous suction and visualization.  Topical fluoride was then placed on the teeth.,At the end of the procedure, the child was undraped, extubated, and awakened in the operating room, taken to the recovery room, breathing spontaneously with stable vital signs.,FINDINGS: , This patient presented in her permanent dentition.  Her teeth #1, 16, 17, and 32 were impacted and are going to be removed following my full mouth dental rehabilitation by Dr. Alexander.  Oral hygiene was fair.  There was generalized plaque and calculus throughout.  She did not have any caries, did not require any restorative dentistry.,CONCLUSION:,  Following my dental surgery, the patient continued to intubated and was prepped for oral surgery procedures by Dr. X and his associates.  There were no postop pain requirements.  I did not have any specific requirements for the patient or her mother and that will be handled by Dr. X and their instructions on soft foods, etc., and pain control will be managed by them.
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DESCRIPTION: Dental prophylaxis under general anesthesia.

surgery, dental prophylaxis, impacted wisdom teeth, gingivitis, wisdom teeth, moderate gingivitis, dental rehabilitation, throat pack, digital radiographs, restorative dentistry, impacted, anesthesia, restorative, wisdom, oral, prophylaxis, teeth, dental,

While dental prophylaxis is a routine procedure, performing it under general anesthesia, especially in a hospital setting, adds complexity and certain risks such as anesthesia-related complications. However, there were no complications reported, the blood loss was minimal, and the procedure went smoothly. Given the context, the stakes are moderate due to the use of general anesthesia and the young age of the patient, but not extremely high. The case seems well-managed with coordination between specialists for a comprehensive dental treatment.


Medical Specialty: Surgery
Sample Name: Mammoplasty - 2

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

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

The situation involves a surgical procedure with multiple components: bilateral augmentation mammoplasty, facial TCA peel, and vein stripping. Surgery inherently carries risks such as infection, bleeding, poor wound healing, and potential need for further surgery. The stakes are significant due to these risks and the complexity of multiple procedures being performed in one session. However, the patient was stable post-surgery and the operation was performed following standard protocols.