Medical Specialty: Neurosurgery
Sample Name: Skull Base Reconstruction

PREOPERATIVE DIAGNOSIS:,  Squamous cell carcinoma of right temporal bone/middle ear space.,POSTOPERATIVE DIAGNOSIS: , Squamous cell carcinoma of right temporal bone/middle ear space.,PROCEDURE: , Right temporal bone resection; rectus abdominis myocutaneous free flap for reconstruction of skull base defect; right selective neck dissection zones 2 and 3.,ANESTHESIA: , General endotracheal.,DESCRIPTION OF PROCEDURE:  ,The patient was brought into the operating room, placed on the table in supine position.  General endotracheal anesthesia was obtained in the usual fashion.  The Neurosurgery team placed the patient in pins and after they positioned the patient the right lateral scalp was prepped with Betadine after shave as well as the abdomen.  The neck was prepped as well.  After this was performed, I made a wide ellipse of the conchal bowl with the Bovie and cutting current down through the cartilage of the conchal bowl.  A wide postauricular incision well beyond the mastoid tip extending into the right neck was then incised with the Bovie with the cutting current and a postauricular skin flap developed leaving the excise conchal bowl in place as the auricle was reflected over anterior to the condyle.  After this was performed, I used the Bovie to incise the soft tissue around the temporal bone away from the tumor on to the mandible.  The condyle was skeletonized so that it could be easily seen.  The anterior border of the sternocleidomastoid was dissected out and the spinal accessory nerve was identified and spared.  The neck contents to the hyoid were dissected out.  The hypoglossal nerve, vagus nerve, and spinal accessory nerve were dissected towards the jugular foramen.  The neck contents were removed as a separate specimen.  The external carotid artery was identified and tied off as it entered the parotid and tied with a Hemoclip distally for the future anastomosis.  A large posterior facial vein was identified and likewise clipped for later use.  I then used the cutting and diamond burs to incise the skull above the external auditory canal so as to expose the dura underneath this and extended it posteriorly to the sigmoid sinus, dissecting or exposing the dura to the level of the jugular bulb.  It became evident there was two tumor extending down the eustachian tube medial to the condyle and therefore I did use the router, I mean the side cutting bur to resect the condyle and the glenoid fossa to expose the medial extent of the eustachian tube.  The internal carotid artery was dissected out of the parapharyngeal space into the carotid canal and I drilled carotid canal up until it made.  I dissected the vertical segment of the carotid out as it entered the temporal bone until it made us turn to the horizontal portion.  Once this was dissected out, Dr. X entered the procedure for completion of the resection with the craniotomy.  For details, please see his operative note.,After Dr. X had completed the resection, I then harvested the rectus free flap.  A skin paddle was drawn out next to the umbilicus about 4 x 4 cm.  The skin paddle was incised with the Bovie and down to the anterior rectus sheath.  Sagittal incisions were made up superiorly and inferiorly to the skin paddle and the anterior rectus sheath dissected out above and below the skin paddle.  The sheath was incised to the midline and a small ellipse was made around the fascia to provide blood supply to the overlying skin.  The skin paddle was then sutured to the fascia and muscle with interrupted 3-0 Vicryl.  The anterior rectus sheath was then reflected off the rectus muscle, which was then divided superiorly with the Bovie and reflected out of the rectus sheath to an inferior direction.  The vascular pedicle could be seen entering the muscle in usual fashion.  The muscle was divided inferior to the pedicle and then the pedicle was dissected to the groin to the external iliac artery and vein where it was ligated with two large Hemoclips on each vessel.  The wound was then packed with saline impregnated sponges.  The rectus muscle with attached skin paddle was then transferred into the neck.  The inferior epigastric artery was sutured to the end of the external carotid with interrupted 9-0 Ethilon with standard microvascular technique.  Ischemia time was less than 10 minutes.  Likewise, the inferior epigastric vein was sutured to the end of the posterior facial vein with interrupted 9-0 Ethilon as well.  There was excellent blood flow through the flap and there were no or any issues with the vascular pedicle throughout the remainder of the case.  The wound was irrigated with copious amounts of saline.  The eustachian tube was obstructed with bone wax.  The muscle was then laid into position with the skin paddle underneath the conchal bowl.  I removed most the skin of the conchal bowl de-epithelializing and leaving the fat in place.  The wound was closed in layers overlying the muscle, which was secured superiorly to the muscle overlying the temporal skull.  The subcutaneous tissues were closed with interrupted 3-0 Vicryl.  The skin was closed with skin staples.  There was small incision made in the postauricular skin where the muscle could be seen and the skin edges were sewn directly to the muscle as to the rectus muscle itself.  The skin paddle was closed with interrupted 4-0 Prolene to the edges of the conchal bowl.,The abdomen was irrigated with copious amounts of saline and the rectus sheath was closed with #1 Prolene with the more running suture, taking care to avoid injury to the posterior rectus sheath by the use of ribbon retractors.  The subcutaneous tissues were closed with interrupted 2-0 Vicryl and skin was closed with skin staples.  The patient was then turned over to the Neurosurgery team for awakening after the patient was appropriately awakened.  The patient was then transferred to the PACU in stable condition with spontaneous respirations, having tolerated the procedure well.
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DESCRIPTION: Squamous cell carcinoma of right temporal bone/middle ear space.  Right temporal bone resection; rectus abdominis myocutaneous free flap for reconstruction of skull base defect; right selective neck dissection zones 2 and 3.

neurosurgery, rectus abdominis myocutaneous, skull base defect, squamous cell carcinoma, skull base, squamous cell, rectus sheath, abdominis, muscle, rectus, sheath

The situation involves a highly complex surgical procedure, specifically a skull base reconstruction involving resection of squamous cell carcinoma and reconstruction with a free flap. These types of procedures are highly intricate, involving significant risk due to the delicate anatomy of the skull base, potential complications related to vascular structures, nerve preservation, and the precision required in microvascular surgery. The outcome can greatly affect the patient's recovery, potential complications, and overall quality of life post-surgery. As such, this is a high-stakes medical situation.


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

Medical Specialty: Surgery
Sample Name: Diskectomy

PREOPERATIVE DIAGNOSIS (ES):, Recurrent herniation L4-5 disk with left radiculopathy.,POSTOPERATIVE DIAGNOSIS (ES):, Recurrent herniation L4-5 disk with left radiculopathy.,PROCEDURE:, Redo L4-5 diskectomy left.,COMPLICATIONS:, None.,ANTIBIOTIC (S),: Vancomycin given preoperatively.,ANESTHESIA:, General endotracheal.,ESTIMATED BLOOD LOSS:, 10 mL.,BLOOD REPLACED:, None.,CRYSTALLOID GIVEN:, 800 mL.,DRAIN (S):, None.,DESCRIPTION OF THE OPERATION:, The patient was brought to the operating room in supine position. General endotracheal anesthesia was administered. He was turned into the prone position on the operating table and positioned in the modified knee-chest position with Andrews frame being used. Care was taken to protect pressure points. The back was shaved, scrubbed with Betadine scrub, rinsed with alcohol, and prepped with DuraPrep, and draped in the usual sterile fashion with Ioban drape being used. A midline skin incision was made, excising scar from previous surgery. Dissection was carried down through the subcutaneous tissue with electrocautery technique. The lumbosacral fascia was split to the left of the spinous process, and subperiosteal dissection of the spinous process and lamina, area of previous laminotomy was identified. Cross-table lateral was also made to confirm position. The scar was then loosened from the inferior portion of 4, superior of L5 lamina, and a portion of the lamina was removed. I did identify normal dura. The scar was then lysed from the medial wall. Dura and nerve root were identified and protected with nerve root retractor. The bulging disk fragment was still contained under the longitudinal ligament. A rent was made with the Penfield and a moderately large fragment was removed. The disk space was then entered with a cruciate cut in the annulus, with additional nuclear material being received. When no other fragments could be removed from the disk space, no other fragments were felt in the central canal under the longitudinal ligament, and a Murphy ball could be passed through the foramen without evidence of compression, the decompression was complete. Check was made for CSF leakage, and no evidence of significant epidural bleeding was present. The wound was irrigated with antibiotic solution. Twenty milligrams of Depo-Medrol was placed over the dura and nerve root. A free fat graft from the subcutaneous tissue was then placed over the dura. Closure was obtained with the lumbosacral fascia being reapproximated with #1, running, Vicryl suture. Subcutaneous closure was obtained in layers with 2-0, running, Vicryl suture. Skin closure was obtained with 3-0 Vicryl subcuticular suture. Proxi-Strips and sterile dressing was applied. The skin had been infiltrated with 8 mL of 0.5% Marcaine with epinephrine.,After a sterile dressing was applied, the patient was turned into the supine position on the waiting recovery room stretcher, brought from under the effects of anesthesia, and taken to the recovery room.
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DESCRIPTION: Redo L4-5 diskectomy, left - recurrent herniation L4-5 disk with left radiculopathy.

surgery, herniation, andrews frame, csf leakage, depo-medrol, l4-5, proxi-strips, diskectomy, endotracheal anesthesia, lumbosacral fascia, modified knee-chest position, radiculopathy, supine position, nerve root, duraprep,

The provided scenario describes a surgical procedure (redo L4-5 diskectomy) for a patient with recurrent herniation at the L4-5 disk that causes left radiculopathy. While the operation is routine in the field of spine surgery, surgery always involves inherent risks such as infection, bleeding, or complications related to anesthesia. The situation is higher stakes than a non-surgical medical intervention due to the need for precision and care to address the spinal issue and protect nearby structures, including the dura and nerve roots. However, the report indicates no complications, suggesting the procedure went smoothly. Despite the lack of complications, the inherent risks of surgery and the potential impact on the patient's quality of life make it a medium-high stakes situation.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Surgery
Sample Name: Total Abdominal Hysterectomy - 2

PREOPERATIVE DIAGNOSES:,1.  Enlarged fibroid uterus.,2.  Pelvic pain.,POSTOPERATIVE DIAGNOSES:,1.  Enlarged fibroid uterus.,2.  Pelvic pain.,3.  Pelvic endometriosis.,PROCEDURE PERFORMED: ,Total abdominal hysterectomy.,ANESTHESIA: , General endotracheal and spinal with Astramorph.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , 200 cc.,FLUIDS:  ,2400 cc of crystalloids.,URINE OUTPUT: , 100 cc of clear urine.,INDICATIONS:,  This is a 40-year-old female gravida-0 with a history of longstanding enlarged fibroid uterus.  On ultrasound, the uterus measured 14 cm x 6.5 cm x 7.8 cm.  She had received two dosage of Lupron to help shrink the fibroid.  Her most recent Pap smear was normal.,FINDINGS: , On a manual exam, the uterus is enlarged approximately 14 to 16 weeks size with multiple fibroids palpated.  On laparotomy, the uterus did have multiple pedunculated fibroids, the largest being approximately 7 cm.  The bilateral tubes and ovaries appeared normal.,There was evidence of endometriosis on the posterior wall of the uterus as well as the bilateral infundibulopelvic ligament.  There was some adhesions of the bowel to the left ovary and infundibulopelvic ligament and as well as to the right infundibulopelvic ligament.,PROCEDURE:,  After consent was obtained, the patient was taken to the operating room where spinal anesthetic was first administered and then general anesthetic.  The patient was placed in the dorsal supine position and prepped and draped in normal sterile fashion.  A Pfannenstiel skin incision was made and carried to the underlying Mayo fashion using the second knife.  The fascia was incised in midline and the incision extended laterally using Mayo scissors.  The superior aspect of the fascial incision was grasped with Kocher clamps, tented up, and dissected off the underlying rectus muscle both bluntly and sharply with Mayo scissors.  Attention was then turned to the inferior aspect of the incision, which in a similar fashion was grasped with Kocher clamps, tented up and dissected off the underlying rectus muscles.  The rectus muscles were separated in the midline and the peritoneum was identified, grasped with hemostat, and entered sharply with Metzenbaum scissors.  This incision was extended superiorly and inferiorly with good visualization of the bladder.  The uterus was then brought up out of the incision.  The bowel adhesions were carefully taken down using Metzenbaum scissors.  Good hemostasis was noted at this point.  The self-retaining retractor was then placed.  The bladder blade was placed.  The bowel was gently packed with moist laparotomy sponges and held in place with the blade on the GYN extension.  The uterus was then grasped with a Lahey clamp and brought up out of the incision.  The left round ligament was identified and grasped with Allis clamp and tented up.  A hemostat was passed in the avascular area beneath the round ligament.  A suture #0 Vicryl was used to suture ligate the round ligament.  Two hemostats were placed across the round ligament proximal to the previously placed suture and the Mayo scissors were used to transect the round ligament.  An avascular area of the broad ligament was then identified and entered bluntly.  The suture of #0 Vicryl was then used to suture ligate the left uterovarian ligament.  Two straight Ochsner's were placed across the uterovarian ligament proximal to the previous suture.  The ligament was then transected and suture ligated with #0 Vicryl.  Attention was then turned to the right round ligament, which in a similar fashion was tented up with an Allis clamp.  An avascular area was entered beneath the round ligament using a hemostat and the round ligament was suture ligated and transected.  An avascular area of the broad ligament was then entered bluntly and the right uterovarian ligament was then suture ligated with #0 Vicryl.,Two straight Ochsner's were placed across the ligament proximal to previous suture.  This was then transected and suture ligated again with #0 Vicryl.  The left uterine peritoneum was then identified and grasped with Allis clamps.  The vesicouterine peritoneum was then transected and then entered using Metzenbaum scissors.  This incision was extended across the anterior portion of the uterus and the bladder flap was taken down.  It was sharply advanced with Metzenbaum scissors and then bluntly using a moist Ray-Tec.  The Ray-Tec was left in place at this point to ensure that the bladder was below the level of the cervix.  The bilateral uterine arteries then were skeletonized with Metzenbaum scissors and clamped bilaterally using straight Ochsner's.  Each were then transected and suture ligated with #0 Vicryl.  A curved Ochsner was then placed on either side of the cervix.  The tissue was transected using a long knife and suture ligated with #0 Vicryl.  Incidentally, prior to taking down the round ligaments, a pedunculated fibroid and the right fundal portion of the uterus was injected with Vasopressin and removed using a Bovie.  The cervix was then grasped with a Lahey clamp.  The cervicovaginal fascia was then taken down first using the long-handed knife and then a back handle of the knife to bring the fascia down below the level of the cervix.  A double-pointed scissors were used to enter the vaginal vault below the level of the cervix.  A straight Ochsner was placed on the vaginal vault.  The Jorgenson scissors were used to amputate the cervix and the uterus off of the underlying vaginal tissue.  The vaginal cuff was then reapproximated with #0 Vicryl in a running locked fashion and the pelvis was copiously irrigated.  There was a small area of bleeding noted on the underside of the bladder.  The bladder was tented up using an Allis clamp and a figure-of-eight suture of #3-0 Vicryl was placed with excellent hemostasis noted at this point.  The uterosacral ligaments were then incorporated into the vaginal cuff and the cuff was synched down.  A figure-of-eight suture of #0 Vicryl was placed in the midline of the vaginal cuff in attempt to incorporate the bilateral round ligament.  The round ligament was too short.  It would be a maximal amount of stretch to incorporate, therefore, only the left round ligament was incorporated into the vaginal cuff.  The bilateral adnexal areas were then re-peritonealized with #3-0 Vicryl in a running fashion.  The bladder flap was reapproximated to the vaginal cuff using one interrupted suture.  The pelvis was again irrigated at this point with excellent hemostasis noted.  Approximately 200 cc of saline with methylene blue was placed into the Foley to inflate the bladder.  There was no spillage of blue fluid into the abdomen.  The fluid again was allowed to drain.  All sponges were then removed and the bowel was allowed to return to its anatomical position.  The peritoneum was then reapproximated with #0 Vicryl in a running fashion.  The fascia was reapproximated also with #0 Vicryl in a running fashion.  The skin was then closed with staples.,A previously placed Betadine soaked Ray-Tec was removed from the patient's vagina and sponge stick was used to assess any bleeding in the vaginal vault.  There was no appreciable bleeding.  The patient tolerated the procedure well.  Sponge, lap, and needle counts were correct x2.  The patient was taken to the recovery room in satisfactory condition.  She will be followed immediately postoperatively within the hospital.
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DESCRIPTION: Total abdominal hysterectomy.  Enlarged fibroid uterus, pelvic pain, and pelvic endometriosis.  On laparotomy, the uterus did have multiple pedunculated fibroids.

surgery, pelvic pain, pelvic endometriosis, astramorph, total abdominal hysterectomy, enlarged fibroid, metzenbaum scissors, vaginal cuff, scissors, vaginal, uterus, ligament, hysterectomy, endometriosis, pedunculated, fibroids, infundibulopelvic, uterovarian, abdominal, laparotomy, peritoneum,

The described situation involves a total abdominal hysterectomy, a major surgical procedure to remove the uterus due to conditions such as fibroids, pelvic pain, and endometriosis. Surgery, especially one involving general anesthesia and potential significant blood loss, inherently carries high stakes due to the risks of complications and the need for precision in the execution. However, since the procedure was completed without complications and with all counts correct post-operation, it suggests proper management and reduced immediate risks. Any surgery with general anesthesia and significant tissue manipulation or removal carries considerable stakes but given the outcome described, these are managed effectively.


Medical Specialty: Psychiatry / Psychology
Sample Name: Psych Consult - Altered Mental Status

REASON FOR CONSULT:,  Altered mental status.,HPI:,  The patient is 77-year-old Caucasian man with benign prostatic hypertrophy, status post cardiac transplant 10 years ago who was admitted to the Physical Medicine and Rehab Service for inpatient rehab after suffering a right cerebellar infarct last month.  Last night, he became confused and he eloped from the unit.  When he was found, he became combative.  This a.m., he continued to be aggressive and required administration of four-point soft restraints in addition to Haldol 1 mg intramuscularly.  There was also documentation of him having paranoid thoughts that his wife was going out spending his money instead of being with him in the hospital.  Given this presentation, Psychiatry was consulted to evaluate and offer management recommendations.,The patient states that he does remember leaving the unit looking for his wife, but does not recall becoming combative, needing restrains and emergency medications.  He reports feeling fine currently, denying any complaints.  The patient's wife notes that her husband might be confused and disoriented due to being in the hospital environment.  She admits that he has some difficulty with memory for sometime and becomes irritable when she is not around.  However, he has never become as combative as he has this particular episode.,He negates any symptoms of depression or anxiety.  He also denies any hallucinations or delusions.  He endorses problems with insomnia.  At home, he takes temazepam.  His wife and son note that the temazepam makes him groggy and disoriented at times when he is at home.,PAST PSYCHIATRIC HISTORY:,  He denies any prior psychiatric treatment or intervention.  However, he was placed on Zoloft 10 years ago after his heart transplant, in addition to temazepam for insomnia.  During this hospital course, he was started on Seroquel 20 mg p.o. q.h.s. in addition to Aricept 5 mg daily.  He denies any history of suicidal or homicidal ideations or attempts.,PAST MEDICAL HISTORY:,1.  Heart transplant in 1997.,2.  History of abdominal aortic aneurysm repair.,3.  Diverticulitis.,4.  Cholecystectomy.,5.  Benign prostatic hypertrophy.,ALLERGIES:,  MORPHINE AND DEMEROL.,MEDICATIONS:,1.  Seroquel 50 mg p.o. q.h.s., 25 mg p.o. q.a.m.,2.  Imodium 2 mg p.o. p.r.n., loose stool.,3.  Calcium carbonate with vitamin D 500 mg b.i.d.,4.  Prednisone 5 mg p.o. daily.,5.  Bactrim DS Monday, Wednesday, and Friday.,6.  Flomax 0.4 mg p.o. daily.,7.  Robitussin 5 mL every 6 hours as needed for cough.,8.  Rapamune 2 mg p.o. daily.,9.  Zoloft 50 mg p.o. daily.,10.  B vitamin complex daily.,11.  Colace 100 mg b.i.d.,12.  Lipitor 20 mg p.o. q.h.s.,13.  Plavix 75 mg p.o. daily.,14.  Aricept 5 mg p.o. daily.,15.  Pepcid 20 mg p.o. daily.,16.  Norvasc 5 mg p.o. daily.,17.  Aspirin 325 mg p.o. daily.,SOCIAL HISTORY:,  The patient is a retired paster and missionary to Mexico.  He is still actively involved in his church.  He denies any history of alcohol or substance abuse.,MENTAL STATUS EXAMINATION:,  He is an average-sized white male, casually dressed, with wife and son at bedside.  He is pleasant and cooperative with good eye contact.  He presents with paucity of speech content; however, with regular rate and rhythm.  He is tremulous which is worse with posturing also some increased motor tone noted.  There is no evidence of psychomotor agitation or retardation.  His mood is euthymic and supple and reactive, appropriate to content with reactive affect appropriate to content.  His thoughts are circumstantial but logical.  He defers most of his responses to his wife.  There is no evidence of suicidal or homicidal ideations.  No presence of paranoid or bizarre delusions.  He denies any perceptual abnormalities and does not appear to be responding to internal stimuli.  His attention is fair and his concentration impaired.  He is oriented x3 and his insight is fair.  On mini-mental status examination, he has scored 22 out of 30.  He lost 1 for time, lost 1 for immediate recall, lost 2 for delayed recall, lost 4 for reverse spelling and could not do serial 7s.  On category fluency, he was able to name 17 animals in one minute.  He was unable to draw clock showing 2 minutes after 10.  His judgment seems limited.,LABORATORY DATA:,  Calcium 8.5, magnesium 1.8, phosphorous 3, pre-albumin 27, PTT 24.8, PT 14.1, INR 1, white blood cell count 8.01, hemoglobin 11.5, hematocrit 35.2, and platelet count 255,000.  Urinalysis on January 21, 2007, showed trace protein, trace glucose, trace blood, and small leukocyte esterase.,DIAGNOSTIC DATA:,  MRI of brain with and without contrast done on January 21, 2007, showed hemorrhagic lesion in right cerebellar hemisphere with diffuse volume loss and chronic ischemic changes.,ASSESSMENT:,AXIS I:,1.  Delirium resulting due to general medical condition versus benzodiazepine ,intoxication/withdrawal.,2.  Cognitive disorder, not otherwise specified, would rule out vascular dementia.,3.  Depressive disorder, not otherwise specified.
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DESCRIPTION: Psychiatric Consultation of patient with altered mental status.

This situation involves a psychiatric consultation for a 77-year-old patient with altered mental status, demonstrating both cognitive and behavioral abnormalities following a cerebellar infarct and a complex medical history. The stakes are high because the patient presents a risk of harm to himself or others, as evidenced by his combative behavior and need for restraints. Additionally, there is a need to determine the underlying cause, such as delirium or a cognitive disorder, to prevent future incidents and ensure appropriate treatment. The involvement of psychiatric symptoms combined with a medical history of heart transplant further complicates clinical decision-making. This context involves potentially serious consequences if the situation is not managed properly, both for the patient's safety and medical treatment outcomes.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Metastatic Ovarian Cancer - Consult

REASON FOR CONSULTATION:,  Metastatic ovarian cancer.,HISTORY OF PRESENT ILLNESS: , Mrs. ABCD is a very nice 66-year-old woman who is followed in clinic by Dr. X for history of renal cell cancer, breast cancer, as well as ovarian cancer, which was initially diagnosed 10 years ago, but over the last several months has recurred and is now metastatic.  She last saw Dr. X in clinic towards the beginning of this month.  She has been receiving gemcitabine and carboplatin, and she receives three cycles of this with the last one being given on 12/15/08.  She was last seen in clinic on 12/22/08 by Dr. Y.  At that point, her white count was 0.9 with the hemoglobin of 10.3, hematocrit of 30%, and platelets of 81,000.  Her ANC was 0.5.  She was started on prophylactic Augmentin as well as Neupogen shots.  She has also had history of recurrent pleural effusions with the knee for thoracentesis.  She had two of these performed in November and the last one was done about a week ago.,Over the last 2 or 3 days, she states she has been getting more short of breath.  Her history is somewhat limited today as she is very tired and falls asleep readily.  Her history comes from herself but also from the review of the records.  Overall, her shortness of breath has been going on for the past few weeks related to her pleural effusions.  She was seen in the emergency room this time and on chest x-ray was found to have a new right-sided pulmonic consolidative infiltrate, which was felt to be possibly related to pneumonia.  She specifically denied any fevers or chills.  However, she was complaining of chest pain.  She states that the chest pain was located in the substernal area, described as aching, coming and going and associated with shortness of breath and cough.  When she did cough, it was nonproductive.  While in the emergency room on examination, her vital signs were stable except that she required 5 liters nasal cannula to maintain oxygen saturations.  An EKG was performed, which showed sinus rhythm without any evidence of Q waves or other ischemic changes.  The chest x-ray described above showed a right lower lobe infiltrate.  A V/Q scan was done, which showed a small mismatched defect in the left upper lobe and a mass defect in the right upper lobe.  The findings were compatible with an indeterminate study for a pulmonary embolism.  Apparently, an ultrasound of the lower extremities was done and was negative for DVT.  There was apparently still some concern that this might be pulmonary embolism and she was started on Lovenox.  There was also concern for pneumonia and she was started on Zosyn as well as vancomycin and admitted to the hospital.,At this point, we have been consulted to help follow along with this patient who is well known to our clinic.,PAST MEDICAL HISTORY,1.  Ovarian cancer - This was initially diagnosed about 10 years ago and treated with surgical resection including TAH and BSO.  This has recurred over the last couple of months with metastatic disease.,2.  History of breast cancer - She has been treated with bilateral mastectomy with the first one about 14 years and the second one about 5 years ago.  She has had no recurrent disease.,3.  Renal cell carcinoma - She is status post nephrectomy.,4.  Hypertension.,5.  Anxiety disorder.,6.  Chronic pain from neuropathy secondary to chemotherapy from breast cancer treatment.,7.  Ongoing tobacco use.,PAST SURGICAL HISTORY,1.  Recent and multiple thoracentesis as described above.,2.  Bilateral mastectomies.,3.  Multiple abdominal surgeries.,4.  Cholecystectomy.,5.  Remote right ankle fracture.,ALLERGIES:,  No known drug allergies.,MEDICATIONS: , At home,,1.  Atenolol 50 mg daily,2.  Ativan p.r.n.,3.  Clonidine 0.1 mg nightly.,4.  Compazine p.r.n.,5.  Dilaudid p.r.n.,6.  Gabapentin 300 mg p.o. t.i.d.,7.  K-Dur 20 mEq p.o. daily.,8.  Lasix unknown dose daily.,9.  Norvasc 5 mg daily.,10.  Zofran p.r.n.,SOCIAL HISTORY: , She smokes about 6-7 cigarettes per day and has done so for more than 50 years.  She quit smoking about 6 weeks ago.  She occasionally has alcohol.  She is married and has 3 children.  She lives at home with her husband.  She used to work as a unit clerk at XYZ Medical Center.,FAMILY HISTORY:,  Both her mother and father had a history of lung cancer and both were smokers.,REVIEW OF SYSTEMS: , GENERAL/CONSTITUTIONAL:  She has not had any fever, chills, night sweats, but has had fatigue and weight loss of unspecified amount.  HEENT:  She has not had trouble with headaches; mouth, jaw, or teeth pain; change in vision; double vision; or loss of hearing or ringing in her ears.  CHEST:  Per the HPI, she has had some increasing dyspnea, shortness of breath with exertion, cough, but no sputum production or hemoptysis.  CVS:  She has had the episodes of chest pains as described above but has not had, PND, orthopnea lower extremity swelling or palpitations.  GI:  No heartburn, odynophagia, dysphagia, nausea, vomiting, diarrhea, constipation, blood in her stool, and black tarry stools.  GU:  No dysuria, burning with urination, kidney stones, and difficulty voiding.  MUSCULOSKELETAL:  No new back pain, hip pain, rib pain, swollen joints, history of gout, or muscle weakness.  NEUROLOGIC:  She has been diffusely weak but no lateralizing loss of strength or feeling.  She has some chronic neuropathic pain and numbness as described above in the past medical history.  She is fatigued and tired today and falls asleep while talking but is easily arousable.  Some of this is related to her lack of sleep over the admission thus far.,PHYSICAL EXAMINATION,VITAL SIGNS:  Her T-max is 99.3.  Her pulse is 54, her respirations is 12, and blood pressure 118/61.,GENERAL:  Somewhat fatigued appearing but in no acute distress.,HEENT:  NC/AT.  Sclerae anicteric.  Conjunctiva clear.  Oropharynx is clear without any erythema, exudate, or discharge.,NECK:  Supple.  Nontender.  No elevated JVP.  No thyromegaly.  No thyroid nodules.,CHEST:  Clear to auscultation and percussion bilaterally with decreased breath sounds on the right.,CVS:  Regular rate and rhythm.  No murmurs, gallops or rubs.  Normal S1 and S2.  No S3 or S4.,ABDOMEN:  Soft, nontender, nondistended.  Normoactive bowel sounds.  No guarding or rebound.  No hepatosplenomegaly.  No masses.
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DESCRIPTION: A very pleasant 66-year-old woman with recurrent metastatic ovarian cancer.

This is a medical consultation involving a 66-year-old woman with a history of multiple serious conditions, including recurrent metastatic ovarian cancer, pulmonary complications, and additional past cancers. The consultation reflects a complex and serious medical situation with multiple potential complications, such as pneumonia and pulmonary embolism, that require careful management. The involvement of metastatic cancer, potential respiratory failure, and previous complex medical history indicates a high-stakes situation where the patient's health is critically at risk.


Medical Specialty: Diets and Nutritions
Sample Name: Dietary Consult - 2

SUBJECTIVE:,  The patient's assistant brings in her food diary sheets.  The patient says she stays active by walking at the mall.,OBJECTIVE:,  Weight today is 201 pounds, which is down 3 pounds in the past month.  She has lost a total of 24 pounds.  I praised this and encouraged her to continue.  I went over her food diary.  I praised her three-meal pattern and all of her positive food choices, especially the use of sugar-free Kool-Aid, sugar-free Jell-O, sugar-free lemonade, diet pop, as well as the variety of foods she is using in her three-meal pattern.  I encouraged her to continue all of this.,ASSESSMENT:,  The patient has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity.  She needs to continue all this.,PLAN:,  Followup is set for 06/13/05 to check the patient's weight, her food diary, and answer any questions.
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DESCRIPTION: The patient has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity.

diets and nutritions, food diary sheets, active, balanced diet, three-meal pattern, weight loss, sugar free, food diary, dietary, weight, meal, diary, sheets, food

The situation described involves monitoring a patient's progress in a weight loss program. While maintaining a healthy weight can significantly impact an individual's overall health and wellbeing, the scenario provided is routine and does not imply any immediate risk to the patient's life or long-term health. This is a typical follow-up in dietary consultations, where the focus is on encouraging positive behaviors that are already in place.


Medical Specialty: Consult - History and Phy.
Sample Name: Congestion - 21-day-old

CHIEF COMPLAINT:,  Congestion, tactile temperature.,HISTORY OF PRESENT ILLNESS: , The patient is a 21-day-old Caucasian male here for 2 days of congestion - mom has been suctioning yellow discharge from the patient's nares, plus she has noticed some mild problems with his breathing while feeding (but negative for any perioral cyanosis or retractions).  One day ago, mom also noticed a tactile temperature and gave the patient Tylenol.,Baby also has had some decreased p.o. intake.  His normal breast-feeding is down from 20 minutes q.2h. to 5 to 10 minutes secondary to his respiratory congestion.  He sleeps well, but has been more tired and has been fussy over the past 2 days.  The parents noticed no improvement with albuterol treatments given in the ER.  His urine output has also decreased; normally he has 8 to 10 wet and 5 dirty diapers per 24 hours, now he has down to 4 wet diapers per 24 hours.  Mom denies any diarrhea.  His bowel movements are yellow colored and soft in nature.,The parents also noticed no rashes, just his normal neonatal acne.  The parents also deny any vomiting, apnea.,EMERGENCY ROOM COURSE: , In the ER, the patient received a lumbar puncture with CSF fluid sent off for culture and cell count.  This tap was reported as clear, then turning bloody in nature.  The patient also received labs including a urinalysis and urine culture, BMP, CBC, CRP, blood culture.  This patient also received as previously noted, 1 albuterol treatment, which did not help his respiratory status.  Finally, the patient received 1 dose of ampicillin and cefotaxime respectively each.,REVIEW OF SYSTEMS: , See above history of present illness.  Mom's nipples are currently cracked and bleeding.  Mom has also noticed some mild umbilical discharge as well as some mild discharge from the penile area.  He is status post a circumcision.  Otherwise, review of systems is negative.,BIRTH/PAST MEDICAL HISTORY: , The patient was an 8 pounds 13 ounces' term baby born 1 week early via a planned repeat C-section.  Mom denies any infections during pregnancy, except for thumb and toenail infections, treated with rubbing alcohol (mom denies any history of boils in the family).  GBS status was negative.  Mom smoked up to the last 5 months of the pregnancy.  Mom and dad both deny any sexually transmitted diseases or genital herpetic lesions.  Mom and baby were both discharged out of the hospital last 48 hours.  This patient has received no hospitalizations so far.,PAST SURGICAL HISTORY:,  Circumcision.,ALLERGIES: , No known drug allergies.,MEDICATIONS:,  Tylenol.,IMMUNIZATIONS:,  None of the family members this year have received a flu vaccine.,SOCIAL HISTORY:,  At home lives mom, dad, a 2-1/2-year-old brother, and a 5-1/2-year-old maternal stepbrother.  Both brothers at home are sick with cold symptoms including diarrhea and vomiting.  The brother (2-1/2-year-old) was seen in the ER tonight with this patient and discharged home with an albuterol prescription.  A nephew of the mom with an ear infection.  Mom also states that she herself was sick with the flu soon after delivery.  There has been recent travel exposure to dad's family over the Christmas holidays.  At this time, there is also exposure to indoor cats and dogs.  This patient also has positive smoking exposure coming from mom.,FAMILY HISTORY: , Paternal grandmother has diabetes and hypertension, paternal grandfather has emphysema and was a smoker.  There are no children needing the use of a pediatric subspecialist or any childhood deaths less than 1 year of age.,PHYSICAL EXAMINATION:  ,VITALS:  Temperature max is 99, heart rate was 133 to 177, blood pressure is 114/43 (while moving), respiratory rate was 28 to 56 with O2 saturations 97 to 100% on room air.  Weight was 4.1 kg.,GENERAL:  Not in acute distress, sneezing, positive congestion with breaths taken.,HEENT:  Normocephalic, atraumatic head.  Anterior fontanelle was soft, open, and flat.  Bilateral red reflexes were positive.  Oropharynx is clear with palate intact, negative rhinorrhea.,CARDIOVASCULAR:  Heart was regular rate and rhythm with a 2/6 systolic ejection murmur heard best at the upper left sternal border, vibratory in nature.  Capillary refill was less than 3 seconds.,LUNGS:  Positive upper airway congestion, transmitted sounds; negative retractions, nasal flaring, or wheezes.,ABDOMEN:  Bowel sounds are positive, nontender, soft, negative hepatosplenomegaly.  Umbilical site was with scant dried yellow discharge.,GU:  Tanner stage 1 male, circumcised.  There was mild hyperemia to the penis with some mild yellow dried discharge.,HIPS:  Negative Barlow or Ortolani maneuvers.,SKIN:  Positive facial erythema toxicum.,LABORATORY DATA: , CBC drawn showed a white blood cell count of 14.5 with a differential of 25 segmental cells, 5% bands, 54% lymphocytes.  The hemoglobin was 14.4, hematocrit was 40.  The platelet count was elevated at 698,000.  A CRP was less than 0.3.,A hemolyzed BMP sample showed a sodium of 139, potassium of 5.6, chloride 105, bicarb of 21, and BUN of 4, creatinine 0.4, and a glucose of 66.,A cath urinalysis was negative.,A CSF sample showed 0 white blood cells, 3200 red blood cells (again this was a bloody tap per ER personnel), CSF glucose was 41, CSF protein was 89.  A Gram stain showed rare white blood cells, many red blood cells, no organisms.,ASSESSMENT: , A 21-day-old with:,1.  Rule out sepsis.,2.  Possible upper respiratory infection.,Given the patient's multiple sick contacts, he is possibly with a viral upper respiratory infection causing his upper airway congestion plus probable fever.  The bacterial considerations although to consider in this child include group B streptococcus, E. coli, and Listeria.  We should also consider herpes simplex virus, although these 3200 red blood cells from his CSF could be due to his bloody tap in the ER.  Also, there is not a predominant lymphocytosis of his CSF sample (there is 0 white blood cell count in the cell count).,Also to consider in this child is RSV.  The patient though has more congested, nasal breathing more than respiratory distress, for example retractions, desaturations, or accessory muscle use.  Also, there is negative apnea in this patient.,PLAN:  ,1.  We will place this patient on the rule out sepsis pathway including IV antibiotics, ampicillin and gentamicin for at least 48 hours.,2.  We will follow up with his blood, urine, and CSF cultures.
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DESCRIPTION: Congestion, tactile temperature.

Congestion, tactile temperature.

This situation involves a 21-day-old infant with potential sepsis or a severe infection, which can be life-threatening in newborns. The stakes are high due to the infant's young age and the symptoms of congestion, decreased feeding, tactile temperature, and a history suggestive of possible serious infections like sepsis or RSV. The child has multiple sick contacts, enhancing the urgency. The infant's current treatment includes antibiotics and close monitoring for potentially life-threatening conditions.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Laparoscopy

PREOPERATIVE DIAGNOSIS:,  Pelvic pain.,POSTOPERATIVE DIAGNOSES:,1.  Pelvic pain.,2.  Pelvic endometriosis.,3.  Pelvic adhesions.,PROCEDURE PERFORMED:,1.  Laparoscopy.,2.  Harmonic scalpel ablation of endometriosis.,3.  Lysis of adhesions.,4.  Cervical dilation.,ANESTHESIA:  ,General.,SPECIMEN:  ,Peritoneal biopsy.,ESTIMATED BLOOD LOSS:,  Scant.,COMPLICATIONS: , None.,FINDINGS: , On bimanual exam, the patient has a small, anteverted, and freely mobile uterus with no adnexal masses.  Laparoscopically, the patient has large omental to anterior abdominal wall adhesions along the left side of the abdomen extending down to the left adnexa.  There are adhesions involving the right ovary to the anterior abdominal wall and the bowel.  There are also adhesions from the omentum to the anterior abdominal wall near the liver.  The uterus and ovaries appear within normal limits other than the adhesions.  The left fallopian tube grossly appeared within normal limits.  The right fallopian tube was not well visualized but appeared grossly scarred and no tubal end was visualized.  There was a large area of endometriosis, approximately 1 cm wide in the left ovarian fossa and there was a small spot of endometriosis in the posterior cul-de-sac.  There was also vesicular appearing endometriosis lesion in the posterior cul-de-sac.,PROCEDURE:  ,The patient was taken in the operating room and generalized anesthetic was administered.  She was then positioned in the dorsal lithotomy position and prepped and draped in the normal sterile fashion.  After exam under anesthetic, weighted speculum was placed in the vagina.  The anterior lip of the cervix was grasped with vulsellum tenaculum.  The uterus was sounded and then was serially dilated with Hank dilators to a size 10 Hank, then the uterine manipulator was inserted and attached to the anterior lip of the cervix.  At this point, the vulsellum tenaculum was removed along with the weighted speculum and attention was turned towards the abdomen.  An approximately 2 cm incision was made immediately inferior to the umbilicus with the skin knife.  The superior aspect of the umbilicus was grasped with a towel clamp.  The abdomen was tented up and a Veress needle inserted through this incision.  When the Veress needle was felt to be in place, deep position was checked by placing saline in the needle.  This was seen to freely drop in the abdomen so it was connected to CO2 gas.  Again, this was started at the lowest setting, was seen to flow freely, so it was advanced to the high setting.  The abdomen was then insufflated to an adequate distention.  Once an adequate distention was reached, the CO2 gas was disconnected.  The Veress needle was removed and a size #11 step trocar was placed.  Next, the laparoscope was inserted through this port.  The medial port was connected to CO2 gas.  Next, a 1 cm incision was made in the midline approximately 2 fingerbreadths above the pubic symphysis.  Through this, a Veress needle was inserted followed by size #5 step trocar and this procedure was repeated under direct visualization on the right upper quadrant lateral to the umbilicus and a size #5 trocar was also placed.  Next, a grasper was placed through the suprapubic port.  This was used to grasp the bowel that was adhesed to the right ovary and the Harmonic scalpel was then used to lyse these adhesions.  Bowel was carefully examined afterwards and no injuries or bleeding were seen.  Next, the adhesions touching the right ovary and anterior abdominal wall were lysed with the Harmonic scalpel and this was done without difficulty.  There was a small amount of bleeding from the anterior abdominal wall peritoneum.  This was ablated with the Harmonic scalpel.  The Harmonic scalpel was used to lyse and ablate the endometriosis in the left ovarian fossa and the posterior cul-de-sac.  Both of these areas were seen to be hemostatic.  Next, a grasper was placed and was used to bluntly remove the vesicular lesion from the posterior cul-de-sac.  This was sent to pathology.  Next, the pelvis was copiously irrigated with the Nezhat dorsi suction irrigator and the irrigator was removed.  It was seen to be completely hemostatic.  Next, the two size #5 ports were removed under direct visualization.  The camera was removed.  The abdomen was desufflated.  The size #11 introducer was replaced and the #11 port was removed.,Next, all the ports were closed with #4-0 undyed Vicryl in a subcuticular interrupted fashion.  The incisions were dressed with Steri-Strips and bandaged appropriately and the patient was taken to recovery in stable condition and she will be discharged home today with Darvocet for pain and she will follow-up in one week in the clinic for pathology results and to have a postoperative check.
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DESCRIPTION: Pelvic pain, pelvic endometriosis, and pelvic adhesions.  Laparoscopy, Harmonic scalpel ablation of endometriosis, lysis of adhesions, and cervical dilation.  Laparoscopically, the patient has large omental to anterior abdominal wall adhesions along the left side of the abdomen extending down to the left adnexa.

obstetrics / gynecology, pelvic pain, endometriosis, pelvic adhesions, laparoscopy, scalpel ablation, lysis of adhesions, cervical dilation, peritoneal biopsy, harmonic scalpel, adhesions, harmonic, scalpel, abdominal, pelvic, abdomen, anterior,

The procedure involves a complex surgical intervention to address diagnosed conditions such as pelvic pain, endometriosis, and adhesions. While the surgery is routine in gynecological practice and was completed without complications - with the patient stable for discharge the same day - it is still a high-stakes medical procedure due to the potential for severe pain, reproductive issues, and other complications if untreated. The use of general anesthesia and the invasiveness of the procedure also elevate the stakes, though they are balanced by the successful and routine handling of the situation.


Medical Specialty: General Medicine
Sample Name: Discharge Summary - 18

ADMISSION DIAGNOSES:,1.  Atypical chest pain.,2.  Nausea.,3.  Vomiting.,4.  Diabetes.,5.  Hypokalemia.,6.  Diarrhea.,7.  Panic and depression.,8.  Hypertension.,DISCHARGE DIAGNOSES:,1.  Serotonin syndrome secondary to high doses of Prozac.,2.  Atypical chest pain with myocardial infarction ruled out.,3.  Diabetes mellitus.,4.  Hypertension.,5.  Diarrhea resolved.,ADMISSION SUMMARY: , The patient is a 53-year-old woman with history of hypertension, diabetes, and depression.  Unfortunately her husband left her 10 days prior to admission and she developed severe anxiety and depression.  She was having chest pains along with significant vomiting and diarrhea.  Of note, she had a nuclear stress test performed in February of this year, which was normal.  She was readmitted to the hospital to rule out myocardial infarction and for further evaluation.,ADMISSION PHYSICAL: , Significant for her being afebrile.  Apparently there was one temperature registered mildly high at 100.  Her blood pressure was 140/82, heart rate 83, oxygen saturation was 100%.  She was tearful.  HEART:  Heart sounds were regular.  LUNGS:  Clear.  ABDOMEN:  Soft.  Apparently there were some level of restlessness and acathexia.  She was also pacing.,ADMISSION LABS:  ,Showed CBC with a white count of 16.9, hematocrit of 46.9, platelets 318,000.  She had 80% neutrophils, no bands.  UA on 05/02 came out negative.  Chemistry panel shows sodium 138, potassium 3.5, creatinine 0.6, calcium 8.3, lactate 0.9, ALT was 39, AST 38, total bilirubin 0.6.  Her initial CK came out at 922.  CK-MB was low.  Troponin was 0.04.  She had a normal amylase and lipase.  Previous TSH few days prior was normal.  Chest x-ray was negative.,HOSPITAL COURSE:,1.  Serotonin syndrome.  After reevaluation of the patient including evaluation of the lab abnormalities it was felt that she likely had serotonin syndrome with obvious restlessness, increased bowel activity, agitation, and elevated white count and CPK.  She did not have fever, tremor or hyperreflexia.  Her CPK improved with IV fluids.  She dramatically improved with this discontinuation of her Prozac.  Her white count came back down towards normal.  At time of discharge, she was really feeling back to normal.,2.  Depression and anxiety with history of panic attacks exacerbated by her husband leaving her 2 weeks ago.  We discussed this.  Also, discussed the situation with a psychiatrist who is available on Friday and I discussed the situation with the patient.  In regards to her medications, we are discontinuing the Prozac and she is being reevaluated by Dr. X on Monday or Tuesday.  Cymbalta has been recommended as a good alternative medication for her.  The patient does have a counselor.  It is going to be difficult for her to go home alone.  I discussed the resources with her.  She has a daughter who will be coming to town in a couple of weeks, but she does have a friend that she can call and stay the next few days with.,3.  Hypertension.  She will continue on her usual medications.,4.  Diabetes mellitus.  She will continue on her usual medications.,5.  Diarrhea resolved.  Her electrolyte abnormalities resolved.  She had received fluid rehydration.,DISPOSITION:,  She is being discharged to home.  She will stay with a friend for a couple of days.  She will be following up with Dr. X on Monday or Tuesday.  Apparently Dr. Y has already discussed the situation and the plan with her.  She will continue on her usual medications except for discontinuing the Prozac.,DISCHARGE MEDICATIONS: , Include,1.  Omeprazole 20 mg daily.,2.  Temazepam 15 mg at night.,3.  Ativan 1 mg one-half to one three times a day as needed.,4.  Cozaar 50 daily.,5.  Prandin 1 mg before meals.,6.  Aspirin 81 mg.,7.  Multivitamin daily.,8.  Lantus 60 units at bedtime.,9.  Percocet 10/325 one to two at night for chronic pain.  She is running out of that, so we are calling a prescription for #10 of those.
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DESCRIPTION: The patient is a 53-year-old woman with history of hypertension, diabetes, and depression.  Serotonin syndrome secondary to high doses of Prozac and atypical chest pain with myocardial infarction ruled out.

The situation involves a patient being discharged from a hospital after experiencing multiple medical issues including serotonin syndrome, depression, anxiety, diabetes, and hypertension. While the medical concerns have been addressed before discharge, they require careful monitoring and follow-up care. The patient is still dealing with significant emotional stress due to personal circumstances, which could impact her health. The necessary coordination of healthcare, medication changes, and social support elevate the stakes. However, the patient has been stabilized enough to be safely discharged, and follow-up care is planned.


Medical Specialty: Orthopedic
Sample Name: Pediatric Rheumatology Consult

HISTORY:  ,We had the pleasure of seeing the patient today in our Pediatric Rheumatology Clinic.  He was sent here with a chief complaint of joint pain in several joints for few months.  This is a 7-year-old white male who has no history of systemic disease, who until 2 months ago, was doing well and 2 months ago, he started to complain of pain in his fingers, elbows, and neck.  At this moment, this is better and is almost gone, but for several months, he was having pain to the point that he would cry at some point.  He is not a complainer according to his mom and he is a very active kid.  There is no history of previous illness to this or had gastrointestinal problems.  He has problems with allergies, especially seasonal allergies and he takes Claritin for it.  Other than that, he has not had any other problem.  Denies any swelling except for that doctor mentioned swelling on his elbow.  There is no history of rash, no stomach pain, no diarrhea, no fevers, no weight loss, no ulcers in his mouth except for canker sores.  No lymphadenopathy, no eye problems, and no urinary problems.,MEDICATIONS: , His medications consist only of Motrin only as needed and Claritin currently for seasonal allergies and rhinitis.,ALLERGIES: , He has no allergies to any drugs.,BIRTH HISTORY:  ,Pregnancy and delivery with no complications.  He has no history of hospitalizations or surgeries.,FAMILY HISTORY: , Positive for arthritis in his grandmother.  No history of pediatric arthritis.  There is history of psoriasis in his dad.,SOCIAL HISTORY: , He lives with mom, dad, brother, sister, and everybody is healthy.  They live in Easton.  They have 4 dogs, 3 cats, 3 mules and no deer.  At school, he is in second grade and he is doing PE without any limitation.,PHYSICAL EXAMINATION: ,VITAL SIGNS:  Temperature is 98.7, pulse is 96, respiratory rate is 24, height is 118.1 cm, weight is 22.1 kg, and blood pressure is 61/44.,GENERAL:  He is alert, active, in no distress, very cooperative.,HEENT:  He has no facial rash.  No lymphadenopathy.  Oral mucosa is clear.  No tonsillitis.  His ear canals are clear and pupils are reactive to light and accommodation.,CHEST:  Clear to auscultation.,HEART:  Regular rhythm and no murmur.,ABDOMEN:  Soft, nontender with no visceromegaly.,MUSCULOSKELETAL:  Shows no limitation in any of his joints or active swelling today.  He has no tenderness either in any of his joints.  Muscle strength is 5/5 in proximal muscles.,LABORATORY DATA:,  Includes an arthritis panel.  It has normal uric acid, sedimentation rate of 2, rheumatoid factor of 6, and antinuclear antibody that is negative and C-reactive protein that is 7.1.  His mother stated that this was done while he was having symptoms.,ASSESSMENT AND PLAN: , This patient may have had reactive arthritis.  He is seen frequently and the patient has family history of psoriatic arthritis or psoriasis.  I do not see any problems at this moment on his laboratories or on his physical examination.  This may have been related to recent episode of viral infection or infection of some sort.  Mother was oriented about the finding and my recommendation is to observe him and if there is any recurrence of the symptoms or persistence of swelling or limitation in any of his joints, I will be glad to see him back.,If you have any question on further assessment and plan, please do no hesitate to contact us.
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DESCRIPTION: A 7-year-old white male started to complain of pain in his fingers, elbows, and neck.  This patient may have had reactive arthritis.

orthopedic, rheumatology, pediatric, reactive arthritis, psoriatic arthritis, psoriasis, joints, swelling, arthritis,

The situation involves a medical consultation for a 7-year-old experiencing joint pain and potential pediatric rheumatological issues. While the symptoms have subsided, there's a need for monitoring due to his age, family history, and lack of a definitive diagnosis. However, it's not an immediate life-threatening situation, as there are no active symptoms or alarming lab results, and the plan is to observe for reoccurrence. Thus, the stakes are moderate, involving careful monitoring and consultation if symptoms reappear.


Medical Specialty: Discharge Summary
Sample Name: Discharge Summary - Peripheral vascular disease

ADMITTING DIAGNOSIS:,  A nonhealing right below-knee amputation.,DISCHARGE DIAGNOSIS:,  A nonhealing right below-knee amputation.,SECONDARY DIAGNOSES:,  Include:,1.  Peripheral vascular disease, bilateral carotid artery stenosis status post bilateral carotid endarterectomies.,2.  Peripheral vascular disease status post aortobifemoral bypass and bilateral femoropopliteal bypass grafting.,3.  Hypertension.,4.  Diverticulosis.,5.  Hypothyroidism.,6.  Chronic renal insufficiency.,7.  Status post open incision and drainage of an intestinal abscess at an unknown point.,DETERMINATION: , Status post right below-knee amputation.,OPERATIONS PERFORMED:,1.  Extensive debridement of right below-knee amputation with debridement of skin, subcutaneous tissue, muscle, and bone on July 17, 2008.,2.  Irrigation and debridement of right below-knee amputation wound on July 21, 2008, July 24, 2008, July 28, 2008, and August 1, 2008.,HISTORY OF PRESENT ILLNESS: , The patient is an 89-year-old gentleman with multiple medical conditions including coronary artery disease, hypothyroidism, and severe peripheral vascular disease status post multiple revascularizations, and a right below-knee amputation in June 2008 following a thrombosis of his right femoropopliteal bypass graft.  Following his amputation, he had poor wound healing.  He presented to the ED with pain in his right lower extremity on July 9, 2008.  Due to concern for infection at that time, he was started on oral Keflex and instructed to follow up with the Vascular Clinic as scheduled.  At his follow-up appointment, it was decided to re-admit The patient for debridement and revision of his stump wound.,HOSPITAL COURSE:,  Briefly, The patient underwent extensive debridement of his right below-knee amputation wound on July 17, 2008.  He underwent debridement of skin, subcutaneous tissue, muscle, and bone to remove the necrotic tissue from the stump.  A wound VAC. was also placed to help accelerate wound healing.  The patient's postoperative course was complicated initially by acute blood-loss anemia, requiring blood transfusion.  He returned to the OR on Monday, July 21, 2008 for irrigation and debridement of his right below-knee amputation and a wound VAC change.  Again, on July 24, 2008, and then again on July 28, 2008, The patient returned to the operating room for irrigation and debridement of his wound and wound VAC change.  Following his procedure on July 28, 2008, The patient began having recurrent episodes of diarrhea, prompting stool cultures and C. difficile assay to be sent.  He was also started on Flagyl, empirically.  C. difficile assay returned positive and the decision was made to continue Flagyl for a full 14-day course.  On July 31, 2008, the patient began experiencing shortness of breath and wheezing after standing to be weighed.  His vital signs remained stable.  However, his oxygen saturation dropped to 93%, improving only to 97% after an addition of 2 liters by nasal cannula.  A chest x-ray revealed bilateral pleural effusions and bibasilar atelectasis in addition to some pulmonary edema diffusely.  The patient's IV fluids were decreased.  He was given p.r.n. albuterol and infusion of Lasix, resulting in significant urine output.  His symptoms of shortness of breath gradually improved.  On August 1, 2008, he returned to the OR for final irrigation and debridement of his below-knee amputation.  Again, a wound VAC was placed.  Postoperatively, he did well.  His Foley catheter was removed.  His vital signs remained stable, and his respiratory status also remained stable.  Arrangements were made for home health and wound VAC care upon discharge.,DISCHARGE CONDITION: , The patient is resting comfortably.  He denies shortness of breath or chest pain.  He has mild bibasilar wheezing, but breathing is otherwise nonlabored.  All other exams normal.,DISCHARGE MEDICATIONS:,1.  Acetaminophen 325 mg daily.,2.  Albuterol 2 puffs every six hours as needed.,3.  Vitamin C 500 mg one to two times daily.,4.  Aspirin 81 mg daily.,5.  Symbicort 1 puff every morning and 1 puff every evening.,6.  Tums p.r.n.,7.  Calcium 600 mg plus vitamin D daily.,8.  Plavix 75 mg daily.,9.  Clorazepate dipotassium 7.5 mg every six hours as needed.,10.  Lexapro 10 mg daily at bedtime.,11.  Hydrochlorothiazide 25 mg one-half tablet daily.,12.  Ibuprofen 200 mg three pills as needed.,13.  Imdur 30 mg daily.,14.  Levoxyl 112 mcg daily.,15.  Ativan 0.5 mg one-half tablet every six hours as needed.,16.  Lopressor 50 mg one-half tablet twice daily.,17.  Flagyl 500 mg every six hours for 10 days.,18.  Multivitamin daily.,19.  Nitrostat 0.4 mg to take as directed.,20.  Omeprazole 20 mg daily.,21.  Oxycodone-acetaminophen 5/325 mg every four to six hours as needed for pain.,22.  Lyrica 25 mg daily at bedtime.,23.  Zocor 40 mg one-half tablet daily at bedtime.
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DESCRIPTION: The patient with multiple medical conditions including coronary artery disease, hypothyroidism, and severe peripheral vascular disease status post multiple revascularizations.

The discharge summary involves a patient with multiple serious medical conditions and a complex medical history, including peripheral vascular disease, a recent below-knee amputation, complications from surgery, and post-operative treatment interventions. The risk of complications like infections, re-hospitalizations, and the need for ongoing treatment makes this a high-stakes situation. Discharge planning and management of medications for such a patient are critical to avoid adverse outcomes, such as infection, clotting issues, or exacerbation of underlying conditions. Proper continuation of care and monitoring are crucial for the patient’s recovery and health maintenance.


Medical Specialty: Surgery
Sample Name: Orchiectomy & Testis Fixation

PREOPERATIVE DIAGNOSIS:,  Nonpalpable right undescended testis.,POSTOPERATIVE DIAGNOSIS: , Nonpalpable right undescended testis with atrophic right testis.,PROCEDURES: , Examination under anesthesia, diagnostic laparoscopy, right orchiectomy, and left testis fixation.,ANESTHESIA:  ,General inhalation anesthetic with caudal block.,FLUID RECEIVED:  ,250 mL of crystalloids.,ESTIMATED BLOOD LOSS: , Less than 5 mL.,SPECIMEN:,  The tissue sent to Pathology was right testicular remnant.,ABNORMAL FINDINGS:,  Closed ring on right with atrophic vessels going into the ring and there was obstruction at the shoulder of the ring.  Left had open appearing ring but the scrotum was not filled and vas and vessels going into the ring.,INDICATIONS FOR OPERATION: , The patient is a 2-year-old boy with a right nonpalpable undescended testis.  The plan is for evaluation and repair.,DESCRIPTION OF OPERATION:  ,The patient was taken to the operating room, where surgical consent, operative site, and patient identification were verified.  Once he was anesthetized, a caudal block was placed.  The patient was placed in supine position and examined.  The left testis well within scrotum.  The right was again not palpable despite the patient being asleep with multiple attempts to check.,The patient was then sterilely prepped and draped.  An 8-French feeding tube was then placed within his bladder through the urethra and attached to the drainage.  We then incised the infraumbilical area once he was sterilely prepped and draped, with 15 blade knife, then using Hasson technique with stay stitches in the anterior and posterior rectus fascia sheath of 3-0 Monocryl.  We entered the peritoneum with the 5-mm one-step system.  We then used the short 0-degree lens for laparoscopy.  We then insufflated with carbon dioxide insufflation to pressure of 12 mmHg.  There was no bleeding noted upon evaluation of the abdomen and again the findings were as mentioned with closed ring with vas and vessels going to the left and vessels and absent vas on the right where the closed ring was found.  Because there was no testis found in the abdomen, we then evacuated the gas and closed the fascial sheath with the 3-0 Monocryl tacking sutures.  Then skin was closed with subcutaneous closure of 4-0 Rapide.  A curvilinear upper scrotal incision was made on the right with 15 blade knife and carried down through the subcutaneous tissue with electrocautery.  Electrocautery was used for hemostasis.  A curved tenotomy scissor was used to open the sac.  The tunica vaginalis was visualized and grasped and then dissected up towards external ring.  There was no apparent testicular tissue.  We did remove it, however, tying off the cord structure with a 4-0 Vicryl suture and putting a tagging suture at the base of the tissue sent.  We then closed the subdartos area with the subcutaneous closure of 4-0 chromic.  We then did a similar curvilinear incision on the left side for testicular fixation.  Delivered the testis into the field, which had a type III epididymal attachment and was indeed about 3 to 4 mL in size, which was larger than expected for the patient's age.  We then closed the upper aspect of the subdartos pouch with the 4-0 chromic pursestring suture and placed testis back into the scrotum in the proper orientation and closed the dartos, skin, and subcutaneous closure with 4-0 chromic on left hemiscrotum.  At the end of the procedure, the patient received IV Toradol and had Dermabond tissue adhesive placed on both incisions and left testis was well descended in the scrotum at the end of the procedure.  The patient tolerated procedure well, and was in stable condition upon transfer to the recovery room.
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DESCRIPTION: Examination under anesthesia, diagnostic laparoscopy, right orchiectomy, and left testis fixation.

surgery, diagnostic laparoscopy, caudal block, testis fixation, undescended testis, subcutaneous closure, testis, orchiectomy, laparoscopy, testicular, scrotum

The surgical procedure described, involving diagnostic laparoscopy, orchiectomy, and testis fixation on a young child, is significant but not necessarily life-threatening. The main stakes lie in the potential implications for future reproductive health and the risk associated with any surgery on a child, such as anesthesia-related issues or postoperative complications. However, given the description, it appears the surgery was successful, with low blood loss and the patient was stable post-operation. Considering these factors, the situation has moderate stakes as it pertains to the health and future reproductive potential of a child.


Medical Specialty: Surgery
Sample Name: Peritoneal Dialysis Catheter Insertion

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

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

The situation involves a surgical procedure to insert a peritoneal dialysis catheter for a 14-year-old patient with renal failure. This is a critical medical procedure as it addresses the urgent need for dialysis in a young patient whose previous catheter was removed due to infection. Failure to effectively insert the catheter could lead to severe health consequences. Therefore, this is high-stakes because it directly impacts the patient's ability to manage renal failure through dialysis, which is essential for her health and survival.


Medical Specialty: Surgery
Sample Name: Bunionectomy & Osteotomy

PREOPERATIVE DIAGNOSES:,1.  Hallux valgus, right foot.,2.  Hallux interphalangeus, right foot.,POSTOPERATIVE DIAGNOSES:,1.  Hallux valgus, right foot.,2.  Hallux interphalangeus, right foot.,PROCEDURES PERFORMED:,1.  Bunionectomy with distal first metatarsal osteotomy and internal screw fixation, right foot.,2.  Akin bunionectomy, right toe with internal wire fixation.,ANESTHESIA: , TIVA/local.,HISTORY:  ,This 51-year-old female presents to ABCD preoperative holding area after keeping herself NPO since mid night for a surgery on her painful bunion through her right foot.  The patient has a history of gradual onset of a painful bunion over the past several years.  She has tried conservative methods such as wide shoes, accommodative padding on an outpatient basis with Dr. X all of which have provided inadequate relief.  At this time, she desires attempted surgical correction.  The risks versus benefits of the procedure have been discussed with the patient in detail by Dr. X and the consent is available on the chart for review.,PROCEDURE IN DETAIL: , After IV was established by the Department of Anesthesia, the patient was taken to the operating room via cart and placed on the operative table in supine position and a safety strap was placed across her waist for her protection.  Copious amounts of Webril were applied about the right ankle and a pneumatic ankle tourniquet was placed over the Webril.,After adequate IV sedation was administered by the Department of Anesthesia, a total of 15 cc of 1:1 mixture of 0.5% Marcaine plain and 1% Lidocaine plain was injected into the foot in a standard Mayo block fashion.  The foot was elevated off the table.  Esmarch bandages were used to exsanguinate the right foot.  The pneumatic ankle tourniquet was elevated to 250 mmHg.  The foot was lowered in the operative field and the sterile stockinet was reflected.  A sterile Betadine was wiped away with a wet and dry sponge and one toothpick was used to test anesthesia, which was found to be adequate.  Attention was directed to the first metatarsophalangeal joint, which was found to be contracted, laterally deviated, and had decreased range of motion.  A #10 blade was used to make a 4 cm dorsolinear incision.  A #15 blade was used to deepen the incision through the subcutaneous layer.  All superficial subcutaneous vessels were ligated with electrocautery.  Next, a linear capsular incision was made down the bone with a #15 blade.  The capsule was elevated medially and laterally off the metatarsal head and the metatarsal head was delivered into the wound.  A hypertrophic medial eminence was resected with a sagittal saw taking care not to strike the head.  The medial plantar aspect of the metatarsal head had some erosive changes and eburnation.  Next, a 0.45 inch Kirschner wire was placed with some access guide slightly plantar flexing the metatarsal taking care not to shorten it.  A sagittal saw was used to make a long-arm Austin osteotomy in the usual fashion.  Standard lateral release was also performed as well as a lateral capsulotomy freeing the fibular sesamoid complex.,The capital head was shifted laterally and impacted on the residual metatarsal head.  Nice correction was achieved and excellent bone to bone contact was achieved.  The bone stock was slightly decreased, but adequate.  Next, a 0.45 inch Kirschner wire was used to temporarily fixate the metatarsal capital fragment.  A 2.7 x 18 mm Synthes cortical screw was thrown using standard AO technique.  Excellent rigid fixation was achieved.  A second 2.0 x 80 mm Synthes fully threaded cortical screw was also thrown using standard AO technique at the proximal aspect of the metatarsal head.  Again, an excellent rigid fixation was obtained and the screws were tight.  The temporary fixation was removed.  A medial overhanging bone was resected with a sagittal saw.  The foot was loaded and the hallux was found to have an interphalangeus deformity present.,A sagittal saw was used to make a proximal cut in approximately 1 cm dorsal to the base of the proximal phalanx, leaving a lateral intact cortical hinge.  A distal cut parallel with the nail base was performed and a standard proximal Akin osteotomy was done.,After the wedge bone was removed, the saw blade was reinserted and used to tether the osteotomy with counter-pressure used to close down the osteotomy.  A #15 drill blade was used to drill two converging holes on the medial aspect of the bone.  A #28 gauge monofilament wire was inserted loop to loop and pulled through the bone.  The monofilament wire was twisted down and tapped into the distal drill hole.  The foot was loaded again and the toe had an excellent cosmetic straight appearance and the range of motion of the first metatarsophalangeal joint was then improved.  Next, reciprocating rasps were used to smooth all bony surfaces.  Copious amounts of sterile saline was used to flush the joint.  Next, a #3-0 Vicryl was used to reapproximate the capsular periosteal tissue layer.  Next, #4-0 Vicryl was used to close the subcutaneous layer.  #5-0 Vicryl was used to the close the subcuticular layer in a running fashion.  Next, 1 cc of dexamethasone phosphate was then instilled in the joint.  The Steri-Strips were applied followed by standard postoperative dressing consisting of Owen silk, 4 x 4s, Kling, Kerlix, and Coban.  The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to the digits.  The patient tolerated the above anesthesia and procedure without complications.  She was transported via cart to the Postanesthesia Care Unit with vital signs stable and vascular status intact to the right foot.  She is to be partial weightbearing with crutches.  She is to follow with Dr. X.  She was given emergency contact numbers and instructions to call if problems arise.  She was given prescription for Vicodin ES #25 one p.o. q.4-6h. p.r.n. pain and Naprosyn one p.o. b.i.d.  500 mg.  She was discharged in stable condition.
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DESCRIPTION: Bunionectomy with distal first metatarsal osteotomy and internal screw fixation, right foot.  Akin bunionectomy, right toe with internal wire fixation.

surgery, hallux interphalangeus, osteotomy, bunionectomy, akin, wire fixation, screw fixation, painful bunion, metatarsophalangeal joint, pneumatic ankle, metatarsal head, foot, toe, sagittal, metatarsal

The provided text describes a detailed surgical procedure, specifically a bunionectomy with distal first metatarsal osteotomy and internal screw fixation, as well as an Akin bunionectomy with internal wire fixation. These are routine procedures in the field of orthopedic or podiatric surgery, meant to address hallux valgus and hallux interphalangeus. While any surgical procedure carries inherent risks such as infection, bleeding, or anesthesia-related complications, this type of surgery is generally considered low to moderate in terms of stakes compared to more critical or life-threatening surgeries such as cardiac or neurosurgery. The text specifies that the patient had attempted conservative management, indicating that surgery was a considered next step rather than an immediate emergency situation.


Medical Specialty: Hematology - Oncology
Sample Name: BCCa Excision - Canthus

PREOPERATIVE DIAGNOSIS: , Basal cell carcinoma (0.8 cm diameter), right medial canthus.,POSTOPERATIVE DIAGNOSIS: , Basal cell carcinoma (0.8 cm diameter), right medial canthus.,OPERATION: , Excision basal cell carcinoma (0.8 cm diameter), right medial canthus with frozen section, and reconstruction of defect (1.2 cm diameter) with glabellar rotation flap.,ANESTHESIA:,  Monitored anesthesia care.,JUSTIFICATION: , The patient is an 80-year-old white female with a biopsy-proven basal cell carcinoma of the right medial canthus.  She was scheduled for elective excision with frozen section under local anesthesia as an outpatient.,PROCEDURE: , With an intravenous infusing and under suitable premedication, the patient was placed supine on the operative table.  The face was prepped with pHisoHex draped.  The right medial canthal region and the glabellar region were anesthetized with 1% Xylocaine with 1:100,000 epinephrine.,Under loupe magnification, the lesion was excised with 2 mm margins, oriented with sutures and submitted for frozen section pathology.  The report was "basal cell carcinoma with all margins free of tumor."  Hemostasis was controlled with the Bovie.  Excised lesion diameter was 1.2 cm.  The defect was closed by elevating a left laterally based rotation flap utilizing the glabellar skin.  The flap was elevated with a scalpel and Bovie, rotated into the defect without tension, ***** to the defect with scissors and inset in layer with interrupted 5-0 Vicryl for the dermis and running 5-0 Prolene for the skin.  Donor site was closed in V-Y fashion with similar suture technique.,The wounds were dressed with bacitracin ointment.  The patient was returned to the recovery room in satisfactory condition.  She tolerated the procedure satisfactorily, and then no complications.  Blood loss was essentially nil.
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DESCRIPTION: Excision basal cell carcinoma, right medial canthus with frozen section, and reconstruction of defect with glabellar rotation flap.

hematology - oncology, basal cell carcinoma, excision, bacitracin, canthal region, canthus, frozen section, glabellar, glabellar region, loupe magnification, phisohex, rotation flap, loupe, excision basal cell carcinoma, medial canthus, basal cell, cell carcinoma, basal, cell, carcinoma,

The excision of a basal cell carcinoma, while necessary, is generally not considered a high-stakes procedure as basal cell carcinomas are a common and typically non-aggressive form of skin cancer. The procedure described is an outpatient surgery performed on an elderly patient under local anesthesia. The use of a frozen section during the excision indicates that the goal was to ensure all cancerous tissue was removed during surgery, which is standard for achieving clean margins and avoiding further interventions. Though important for the patient's health, the stakes are not extremely high since the carcinoma is localized and not life-threatening in the immediate sense. The absence of any complications during the procedure also contributes to the assessment of the stakes involved.


Medical Specialty: Surgery
Sample Name: Heart Catheterization & Angiography

INDICATION:,  Coronary artery disease, severe aortic stenosis by echo.,PROCEDURE PERFORMED:,1.  Left heart catheterization.,2.  Right heart catheterization.,3.  Selective coronary angiography.,PROCEDURE: , The patient was explained about all the risks, benefits and alternatives to the procedure.  The patient agreed to proceed and informed consent was signed.,Both groins were prepped and draped in usual sterile fashion.  After local anesthesia with 2% lidocaine, 6-French sheath was inserted in the right femoral artery and 7-French sheath was inserted in the right femoral vein.  Then right heart cath was performed using 7-French Swan-Ganz catheter.  Catheter was placed in the pulmonary capillary wedge position.  Pulmonary capillary wedge pressure, PA pressure was obtained, cardiac output was obtained, then RV, RA pressures were obtained.  The right heart catheter _______ pulled out.  Then selective coronary angiography was performed using 6-French JL4 and 6-French 3DRC catheter.  Then attempt was made to cross the aortic valve with 6-French pigtail catheter, but it was unsuccessful.  After the procedure, catheters were pulled out, sheath was pulled out and hemostasis was obtained by manual pressure.  The patient tolerated the procedure well.  There were no complications.,HEMODYNAMICS:,1.  Cardiac output was 4.9 per liter per minute.  Pulmonary capillary wedge pressure, mean was 7, PA pressure was 20/14, RV 26/5, RA mean pressure was 5.,2.  Coronary angiography, left main is calcified _______ dense complex.,3.  LAD proximal 70% calcified stenosis present and patent stent to the mid LAD and diagonal 1 is a moderate-size vessel, has 70% stenosis.  Left circumflex has diffuse luminal irregularities.  OM1 has 70% stenosis, is a moderate-size vessel.  Right coronary is dominant and has minimal luminal irregularities.,SUMMARY: , Three-vessel coronary artery disease with aortic stenosis by echo with normal pulmonary artery systolic pressure.,RECOMMENDATION: , Aortic valve replacement with coronary artery bypass surgery.
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DESCRIPTION: Left and right heart catheterization and selective coronary angiography.  Coronary artery disease, severe aortic stenosis by echo.

surgery, lad proximal, femoral artery, sheath, catheter, selective coronary angiography, coronary artery disease, pulmonary capillary wedge, capillary wedge, coronary angiography, coronary artery, heart catheterization, catheterization, heart, artery, stenosis, angiography, pressure, coronary

The situation involves a combination of heart catheterization, angiography, and a diagnosis of significant coronary artery disease with severe aortic stenosis, which requires surgical intervention through aortic valve replacement and coronary artery bypass surgery. The procedures mentioned, their findings, and the recommendations are related to cardiac health, which is critical and high-stakes due to the potential for serious complications, including heart attacks or cardiac failure if left untreated.


Medical Specialty: Pediatrics - Neonatal
Sample Name: Pediatric Urology Letter

XYZ, M.D. ,Suite 123, ABC Avenue ,City, STATE 12345 ,RE:  XXXX, XXXX ,MR#:  0000000,Dear Dr. XYZ: ,XXXX was seen in followup in the Pediatric Urology Clinic.  I appreciate you speaking with me while he was in clinic.  He continues to have abdominal pain, and he had a diuretic renal scan, which indicates no evidence of obstruction and good differential function bilaterally. ,When I examined him, he seems to indicate that his pain is essentially in the lower abdomen in the suprapubic region; however, on actual physical examination, he seems to complain of pain through his entire right side.  His parents have brought up the question of whether this could be gastrointestinal in origin and that is certainly an appropriate consideration.  They also feel that since he has been on Detrol, his pain levels have been somewhat worse, and so, I have given them the option of stopping the Detrol initially.  I think he should stay on MiraLax for management of his bowels.  I would also suggest that he be referred to Pediatric Gastroenterology for evaluation.  If they do not find any abnormalities from a gastrointestinal perspective, then the next step would be to endoscope his bladder and then make sure that he does not have any evidence of bladder anatomic abnormalities that is leading to this pain. ,Thank you for following XXXX along with us in Pediatric Urology Clinic.  If you have any questions, please feel free to contact me. ,Sincerely yours,
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DESCRIPTION: He continues to have abdominal pain, and he had a diuretic renal scan, which indicates no evidence of obstruction and good differential function bilaterally.

pediatrics - neonatal, differential function, diuretic renal scan, abdominal pain, renal scan, pediatric urology,

The situation involves a pediatric patient experiencing ongoing abdominal pain with a potential urological or gastrointestinal origin. It is a medical situation that requires careful diagnostic assessments and potentially several referrals. However, no immediate life-threatening condition is mentioned, and the proposed next steps involve further evaluations and adjustments to medication. While the stakes are significant due to the involvement of a child's health, the absence of an acute emergency or highly critical condition suggests moderate stakes.


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

Medical Specialty: Obstetrics / Gynecology
Sample Name: Hysterectomy, BSO, & Appendectomy.

1.  Pelvic tumor.,2.  Cystocele.,3.  Rectocele.,POSTOPERATIVE DIAGNOSES:,1.  Degenerated joint.,2.  Uterine fibroid.,3.  Cystocele.,4.  Rectocele.,PROCEDURE PERFORMED:  ,1.  Total abdominal hysterectomy.,2.  Bilateral salpingooophorectomy.,3.  Repair of bladder laceration.,4.  Appendectomy.,5.  Marshall-Marchetti-Krantz cystourethropexy.,6.  Posterior colpoperineoplasty.,GROSS FINDINGS:  The patient had a history of a rapidly growing mass on the abdomen, extending from the pelvis over the past two to three months.  She had a recent D&C and laparoscopy, and enlarged mass was noted and could not be determined if it was from the ovary or the uterus.  Curettings were negative for malignancy.  The patient did have a large cystocele and rectocele, and a collapsed anterior and posterior vaginal wall.,Upon laparotomy, there was a giant uterine tumor extending from the pelvis up to the above the umbilicus compatible with approximately four to five-month pregnancy.  The ovaries appeared to be within normal limits.  There was marked adherence between the bladder and the giant uterus and mass with edema and inflammation, and during dissection, a laceration inadvertently occurred and it was immediately recognized.  No other pathology noted from the abdominal cavity or adhesions.  The upper right quadrant of the abdomen compatible with a previous gallbladder surgery.  The appendix is in its normal anatomic position.  The ileum was within normal limits with no Meckel's diverticulum seen and no other gross pathology evident.  There was no evidence of metastasis or tumors in the left lobe of the liver.,Upon frozen section, diagnosis of initial and partial is that of a degenerating uterine fibroid rather than a malignancy.,OPERATIVE PROCEDURE:  The patient was taken to the Operating Room, prepped and draped in the low lithotomy position under general anesthesia.  A midline incision was made around the umbilicus down to the lower abdomen.  With a #10 Bard Parker blade knife, the incision was carried down through the fascia.  The fascia was incised in the midline, muscle fibers were splint in the midline, the peritoneum was grasped with hemostats and with a #10 Bard Parker blade after incision was made with Mayo scissors.  A Balfour retractor was placed into the wound.  This giant uterus was soft and compatible with a possible leiomyosarcoma or degenerating fibroid was handled with care.  The infundibular ligament on the right side was isolated and ligated with #0 Vicryl suture brought to an avascular area, doubly clamped and divided from the ovary and the ligament again re-ligated with #0 Vicryl suture.  The right round ligament was ligated with #0 Vicryl suture, brought to an avascular space within the broad ligament and divided from the uterus.  The infundibulopelvic ligament on the left side was treated in a similar fashion as well as the round ligament.  An attempt was made to dissect the bladder flap from the anterior surface of the uterus and this was remarkably edematous and difficult to do, and during dissection the bladder was inadvertently entered.  After this was immediately recognized, the bladder flap was wiped away from the anterior surface of the uterus.  The bladder was then repaired with a running locking stitch #0 Vicryl suture incorporating serosal muscularis mucosa and then the second layer of overlapping seromuscular sutures were used to make a two-layer closure of #0 Vicryl suture.  After removing the uterus, the bladder was tested with approximately 400 cc of sterile water and there appeared to be no leak.  Progressing and removing of the uterus was then carried out and the broad ligament was clamped bilaterally with a straight Ochsner forceps and divided from the uterus with Mayo scissors, and the straight Ochsner was placed by #0 Vicryl suture thus controlling the uterine blood supply.  The cardinal ligaments containing the cervical blood supply was serially clamped bilaterally with a curved Ochsner forceps, divided from the uterus with #10 Bard Parker blade knife and a curved Ochsner was placed by #0 Vicryl suture.  The cervix was again grasped with a Lahey tenaculum and pubovesicocervical ligament was entered and was divided using #10 Bard Parker blade knife and then the vaginal vault and with a double pointed sharp scissors.  A single-toothed tenaculum was placed on the cervix and then the uterus was removed from the vagina using hysterectomy scissors.  The vaginal cuff was then closed using a running #0 Vicryl suture in locking stitch incorporating all layers of the vagina, the cardinal ligaments of the lateral aspect and uterosacral ligaments on the posterior aspect.  The round ligaments were approximated to the vaginal cuff with #0 Vicryl suture and the bladder flap approximated to the round ligaments with #000 Vicryl suture.  The ______ was re-peritonealized with #000 Vicryl suture and then the cecum brought into the incision.  The pelvis was irrigated with approximately 500 cc of water.  The appendix was grasped with Babcock forceps.  The mesoappendix was doubly clamped with curved hemostats and divided with Metzenbaum scissors.  The curved hemostats were placed with #00 Vicryl suture.  The base of the appendix was ligated with #0 plain gut suture, doubly clamped and divided from the distal appendix with #10 Bard Parker blade knife, and the base inverted with a pursestring suture with #00 Vicryl.  No bleeding was noted.  Sponge, instrument, and needle counts were found to be correct.  All packs and retractors were removed.  The peritoneum muscle fascia was closed in single-layer closure using running looped #1 PDS, but prior to closure, a Marshall-Marchetti-Krantz cystourethropexy was carried out by dissecting the space of Retzius identifying the urethra in the vesical junction approximating the periurethral connective tissue to the symphysis pubis with interrupted #0 Vicryl suture.  Following this, the abdominal wall was closed as previously described and the skin was closed using skin staples.  Attention was then turned to the vagina, where the introitus of the vagina was grasped with an Allis forceps at the level of the Bartholin glands.  An incision was made between the mucous and the cutaneous junction and then a midline incision was made at the posterior vaginal mucosa in a tunneling fashion with Metzenbaum scissors.  The flaps were created bilaterally by making an incision in the posterior connective tissue of the vagina and wiping the rectum away from the posterior vaginal mucosa, and flaps were created bilaterally.  In this fashion, the rectocele was reduced and the levator ani muscles were approximated in the midline with interrupted #0 Vicryl suture.  Excess vaginal mucosa was excised and the vaginal mucosa closed with running #00 Vicryl suture.  The bulbocavernosus and transverse perinei muscles were approximated in the midline with interrupted #00 Vicryl suture.  The skin was closed with a running #000 plain gut subcuticular stitch.  The vaginal vault was packed with a Betadine-soaked Kling gauze sponge.  Sterile dressing was applied.  The patient was sent to recovery room in stable condition.
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DESCRIPTION: Pelvic tumor, cystocele, rectocele, and uterine fibroid.  Total abdominal hysterectomy, bilateral salpingooophorectomy, repair of bladder laceration, appendectomy, Marshall-Marchetti-Krantz cystourethropexy, and posterior colpoperineoplasty. She had a recent D&C and laparoscopy, and enlarged mass was noted and could not be determined if it was from the ovary or the uterus.

obstetrics / gynecology, marshall-marchetti-krantz cystourethropexy, pelvic tumor, cystocele, rectocele, uterine fibroid, hysterectomy, salpingooophorectomy, bladder laceration, appendectomy, colpoperineoplasty, marshall marchetti krantz cystourethropexy, bard parker blade knife, vicryl suture, vaginal mucosa, uterus, vaginal, uterine, mucosa, scissors, ligament, bladder

The described situation involves a complex surgical procedure with multiple components, including a total abdominal hysterectomy, bilateral salpingo-oophorectomy, repair of a bladder laceration, appendectomy, and others, performed under general anesthesia. This type of surgery is inherently high-stakes due to the complexity of the procedures involved, the potential for complications (such as the bladder laceration that occurred and was repaired during the procedure), and the critical nature of patient outcomes in gynecological surgery. Additionally, the presence of a large mass that needed careful handling and the significant anatomical changes being addressed in this surgery contribute to its high-stakes nature. The necessity for precise surgical technique and postoperative recovery highlight the serious nature of this case.