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

Medical Specialty: Ophthalmology
Sample Name: Ophthalmology - Letter - 3

XYZ, O.D.,RE:  ABC,DOB:  MM/DD/YYYY,Dear XYZ:,Thank you very much for your kind referral of Mrs. ABC who you referred to me for narrow angles and possible associated glaucoma.  I examined Mrs. ABC initially on MM/DD/YYYY.  At that time, she expressed a chief concern of occasional pain around her eye, but denied any flashing lights, floaters, halos, or true brow ache.  She reports a family history of glaucoma in her mother, but is unsure of the specific kind.  Her past ocular history has been fairly unremarkable.  As you know, she has a history of non-insulin dependent diabetes.  She is unaware of her last hemoglobin A1c levels, but reports a blood sugar of 158 taken on the morning of her appointment with me.  She is followed by Dr. X here locally.,Upon examination, her visual acuity measured 20/20-1 in either eye with her glasses.  Presenting intraocular pressures were14 mmHg in either eye at 2:03 p.m.  Pupillary reactions, confrontational visual fields, and ocular motility were normal.  The slit lamp exam revealed narrow anterior chambers and on gonioscopy only the buried anterior trabecular meshwork was visible in either eye, but the angle deepened with gonio-compression suggesting appositional and not synechial closure.  I deferred the dilated portion of the exam on that day.,We proceeded with peripheral iridectomies and following this upon her most recent visit on MM/DD/YYYY, I was able to safely dilate her eyes as her chambers had deepened and the PIs were patent.  I note that she has an increased CD ratio measuring 0.65 in the right eye and 0.7 in the left and although her FDT visual fields and GDX testing were normal at your office, she does have an enlarged blind spot in either eye on Humphrey visual fields and retinal tomography also shows some suspicious changes.  Therefore, I feel she has sustained some optic nerve damage perhaps from intermittent angle closure in the past.,In summary, Mrs. ABC has a history of narrow angles not successfully treated with laser PIs.  Her intraocular pressures have remained stable.  I will continue to monitor her closely.,Thank you very much once again for allowing me to have shared in her care.  If I can provide any additional information or be of further service, do let me know.,Sincerely,,
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DESCRIPTION: Patient referred for narrow angles and possible associated glaucoma.

ophthalmology, intraocular pressures, narrow angles, visual fields, angles, intraocular, pressures, anterior, chambers, gonioscopy, glaucoma, narrow, visual, eye,

The medical situation involves the diagnosis and ongoing monitoring of a patient who may have glaucoma or related ocular issues. Glaucoma, if untreated, can lead to vision loss, which makes it important but not an immediate high-stakes emergency. The situation is under control with ongoing monitoring and treatment, lowering the stakes. It's significant due to potential vision impairment, but given the current stable state, it doesn't represent an immediate life-threatening risk.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Orthopedic
Sample Name: Orthopedic Consult

REASON FOR CONSULT: , Medical management, status post left total knee arthroplasty.,PAST MEDICAL HISTORY:,1.  Polyarthritis.,2.  Acromegaly.,3.  Hypothyroidism.,4.  Borderline hypertension.,5.  Obesity.,PAST SURGICAL HISTORY: , Hernia repair, resection of tumor, right thumb arthrodesis, carpal tunnel decompression, bilateral hip replacement, right total knee replacement about 2 months ago, open reduction of left elbow fracture.,REVIEW OF SYSTEMS:,CONSTITUTIONAL SYMPTOMS:  No fever or recent general malaise.,ENT:  Not remarkable.,RESPIRATORY:  No cough or shortness of breath.,CARDIOVASCULAR:  The patient denies any heart problems.  No orthopnea.  No palpitations.  No syncopal episodes.,GASTROINTESTINAL:  No nausea.  No vomiting.  No history of GI bleed.,GENITOURINARY:  No dysuria, no hematuria.,ENDOCRINE:  The patient is status post pituitary tumor resection and is on supplemental hormone.,MEDICATIONS:  Depo-Testosterone 200 mg IM q.3 weekly, prednisone 1 tablet p.o. daily, octreotide IM on a monthly basis, morphine extended release 50 mg p.o. b.i.d., Synthroid 100 mcg p.o. daily, desmopressin 1 tablet p.o. every bedtime, aspirin/oxycodone on a p.r.n. basis, aspirin on p.r.n. basis.,ALLERGIES: , IBUPROFEN AND TYLENOL.,SOCIAL HISTORY: , The patient does not smoke nor drink alcohol.,FAMILY HISTORY: , Noncontributory.,PHYSICAL EXAMINATION,GENERAL:  Obese, 57-year-old gentleman, not in acute distress.,VITAL SIGNS:  Blood pressure of 105/55, pulse is 90.  He is afebrile.  O2 saturation is 95% on room air.,HEAD AND NECK:  Face symmetrical.  Cranial nerves are intact.  No distended neck veins.  No palpable neck masses.,CHEST:  Clear to auscultation.  No wheezing.  No crepitations.,CARDIOVASCULAR:  First and second heart sounds were heard.  No murmur was appreciated.,ABDOMEN:  Benign.,EXTREMITIES:  The left knee is in closed dressing.  The lower extremities are still numb from spinal anesthesia.,ASSESSMENT AND PLAN:,1.  Polyarthritis, status post left total knee replacement.  The patient tolerated the procedure well.,2.  Acromegaly, status post pituitary resection.  Continue supplemental hormones.,3.  Borderline hypertension, blood pressure is under control with monitoring.,4.  Deep venous thrombosis prophylaxis as per surgeon.,5.  Anemia due to repeated blood loss with monitor hemoglobin and hematocrit.
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DESCRIPTION: Medical management, status post left total knee arthroplasty.

The case involves post-operative management of a patient who recently underwent a left total knee arthroplasty. There are several pre-existing conditions like polyarthritis, acromegaly, and borderline hypertension that require careful monitoring, particularly to prevent potential complications like deep vein thrombosis (DVT). However, the patient appears to be stable overall, with controlled hypertension and a managed endocrine condition following pituitary surgery. The stakes are relatively moderate, as post-operative complications can arise, but the patient is receiving appropriate follow-up care and monitoring.


Medical Specialty: General Medicine
Sample Name: Normal Physical Exam Template - 3

PHYSICAL EXAMINATION,GENERAL APPEARANCE: , Well developed, well nourished, in no acute distress.,VITAL SIGNS:,  ***,SKIN:  ,Inspection of the skin reveals no rashes, ulcerations or petechiae.,HEENT:,  The sclerae were anicteric and conjunctivae were pink and moist.  Extraocular movements were intact and pupils were equal, round, and reactive to light with normal accommodation.  External inspection of the ears and nose showed no scars, lesions, or masses.  Lips, teeth, and gums showed normal mucosa.  The oral mucosa, hard and soft palate, tongue and posterior pharynx were normal.,NECK:  ,Supple and symmetric.  There was no thyroid enlargement, and no tenderness, or masses were felt.,CHEST: , Normal AP diameter and normal contour without any kyphoscoliosis.,LUNGS: , Auscultation of the lungs revealed normal breath sounds without any other adventitious sounds or rubs.,CARDIOVASCULAR:  ,There was a regular rate and rhythm without any murmurs, gallops, rubs.  The carotid pulses were normal and 2+ bilaterally without bruits.  Peripheral pulses were 2+ and symmetric.,ABDOMEN:  ,Soft and nontender with normal bowel sounds.  The liver span was approximately 5-6 cm in the right midclavicular line by percussion.  The liver edge was nontender.  The spleen was not palpable.  There were no inguinal or umbilical hernias noted.  No ascites was noted.,RECTAL:  ,Normal perineal exam.  Sphincter tone was normal.  There was no external hemorrhoids or rectal masses.  Stool Hemoccult was negative.  The prostate was normal size without any nodules appreciated (men only).,LYMPH NODES: , No lymphadenopathy was appreciated in the neck, axillae or groin.,MUSCULOSKELETAL: , Gait was normal.  There was no tenderness or effusions noted.  Muscle strength and tone were normal.,EXTREMITIES: , No cyanosis, clubbing or edema.,NEUROLOGIC:  ,Alert and oriented x 3.  Normal affect.  Gait was normal.  Normal deep tendon reflexes with no pathological reflexes.  Sensation to touch was normal.
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DESCRIPTION: Normal physical exam template.  Well developed, well nourished, in no acute distress.

The situation involves a description of a normal physical examination template used in general medicine. It doesn't present any pressing issues, critical information, or immediate risks concerning a patient's health. It is routine documentation of a typical, healthy physical condition. There are no indicators of high risk or emergency in this context.


Medical Specialty: Ophthalmology
Sample Name: Blepharoplasty - Quad

PREOPERATIVE DIAGNOSES:,1.  Blepharochalasia.,2.  Lower lid large primary and secondary bagging.,POSTOPERATIVE DIAGNOSES:,1.  Blepharochalasia.,2.  Lower lid large primary and secondary bagging.,PROCEDURE: , Quad blepharoplasty.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Minimal.,CONDITION: , The patient did well.,PROCEDURE:  ,The patient had marks and measurements prior to surgery.  Additional marks and measurements were made at the time of surgery; these were again checked.  At this point, the area was injected with 0.5% lidocaine with 1:200,000 epinephrine.  Appropriate time waited for the anesthetic and epinephrine effect.,Beginning on the left upper lid, the skin excision was completed.  The muscle was opened, herniated, adipose tissue pad in the middle and medial aspect was brought forward, cross-clamped, excised, cauterized, and allowed to retract.  The eyes were kept irrigated and protected throughout the procedure.  Attention was turned to the opposite side.  Procedure was carried out in the similar manner.,At the completion, the wounds were then closed with a running 6-0 Prolene, skin adhesives, and Steri-Strips.  Attention was turned to the right lower lid.  A lash line incision was made.  A skin flap was elevated and the muscle was opened.  Large herniated adipose tissue pads were present in each of the three compartments.  They were individually elevated, cross-clamped, excised, cauterized, and allowed to retract.,At the completion, a gentle tension was placed on the facial skin and several millimeters of the skin excised.  Attention was turned to he opposite side.  The procedure was carried out as just described.  The contralateral side was reexamined and irrigated.  Hemostasis was good and it was closed with a running 6-0 Prolene.  The opposite side was closed in a similar manner.,Skin adhesives and Steri-Strips were applied.  The eyes were again irrigated and cool Swiss Eye compresses applied.  At the completion of the case, the patient was extubated in the operating room, breathing on her own, doing well, and transferred in good condition from operating room to recovering room.
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DESCRIPTION: Quad blepharoplasty for blepharochalasia and lower lid large primary and secondary bagging.

ophthalmology, blepharochalasia, lower lid, swiss eye compresses, adipose tissue pad, bagging, blepharoplasty, lash line incision, quad blepharoplasty,

The described situation involves a quad blepharoplasty, an elective cosmetic surgical procedure to address eyelid concerns such as blepharochalasia and lower lid bagging. While it is a surgical intervention requiring general anesthesia, it is commonly performed and generally considered low-risk when appropriate measures are taken. The postoperative condition mentioned indicates the patient did well, and there was minimal blood loss, suggesting no immediate complications. However, as with any surgery involving anesthesia, there are inherent risks, but these are mitigated in a controlled medical environment, leading to the procedure being considered low to moderate stakes in terms of medical risk.


Medical Specialty: Surgery
Sample Name: Hickman Central Venous Catheter Placement

PROCEDURE PERFORMED,1.  Placement of a subclavian single-lumen tunneled Hickman central venous catheter.,2.  Surgeon-interpreted fluoroscopy.,OPERATION IN DETAIL:,  After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room and anesthesia was administered.  Next, a #18-gauge needle was used to locate the subclavian vein.  After aspiration of venous blood, a J wire was inserted through the needle using Seldinger technique.  The needle was withdrawn.  The distal tip location of the J wire was confirmed to be in adequate position with surgeon-interpreted fluoroscopy.  Next, a separate stab incision was made approximately 3 fingerbreadths below the wire exit site.  A subcutaneous tunnel was created, and the distal tip of the Hickman catheter was pulled through the tunnel to the level of the cuff.  The catheter was cut to the appropriate length.  A dilator and sheath were passed over the J wire.  The dilator and J wire were removed, and the distal tip of the Hickman catheter was threaded through the sheath, which was simultaneously withdrawn.  The catheter was flushed and aspirated without difficulty.  The distal tip was confirmed to be in good location with surgeon-interpreted fluoroscopy.  A 2-0 nylon was used to secure the cuff down to the catheter at the skin level.  The skin stab site was closed with a 4-0 Monocryl.  The instrument and sponge count was correct at the end of the case.  The patient tolerated the procedure well and was transferred to the postanesthesia recovery area in good condition.
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DESCRIPTION: Placement of a subclavian single-lumen tunneled Hickman central venous catheter.  Surgeon-interpreted fluoroscopy.

surgery, j wire, distal tip, stab incision, tunneled, hickman central venous catheter, subclavian, venous, fluoroscopy, hickman, catheterNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.

The placement of a Hickman central venous catheter is a surgical procedure that involves significant complexity and potential risks, such as infection, bleeding, or incorrect catheter placement. These risks necessitate informed consent and careful monitoring during and after the procedure. While this procedure is routinely performed, the implications of error or complications can be serious, as the catheter is used for administering medication and other treatments directly into the central venous system.


Medical Specialty: Surgery
Sample Name: Heart Catheterization, Ventriculography, & Angiography - 2

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

This medical procedure involves a heart catheterization, which is inherently a high-stakes medical operation. It involves potential risks such as myocardial infarction, stroke, and even death, as well as other complications. The procedure is crucial for addressing recurrent angina and managing coronary artery disease, which can be life-threatening if not properly treated. Despite the absence of complications during the procedure, the stakes remain high due to the potential for restenosis and other cardiac issues related to coronary health. Thus, any decision-making around this procedure involves significant stakes due to the associated risks and importance for the patient's heart health.


Medical Specialty: Surgery
Sample Name: Subxiphoid Pericardial Window - 1

OPERATION: , Subxiphoid pericardial window.,ANESTHESIA: , General endotracheal anesthesia.,OPERATIVE PROCEDURE IN DETAIL:  ,After obtaining informed consent from the patient's family, including a thorough explanation of the risks and benefits of the aforementioned procedure, patient was taken to the operating room and general endotracheal anesthesia was administered.  Next, the neck and chest were prepped and draped in the standard surgical fashion.  A #10-blade scalpel was used to make an incision in the area of the xiphoid process.  Dissection was carried down to the level of the fascia using Bovie electrocautery.  The xiphoid process was elevated, and the diaphragmatic attachments to it were dissected free.  Next the pericardium was identified.,The pericardium was opened with Bovie electrocautery.  Upon entering the pericardium, serous fluid was expressed.  In total, ** cc of fluid was drained.  A pericardial biopsy was obtained.  The fluid was sent off for cytologic examination as well as for culture.  A #24 Blake chest drain was brought out through the skin and placed in the posterior pericardium.  The fascia was closed with #1 Vicryl followed by 2-0 Vicryl followed by 4-0 PDS in a running subcuticular fashion.  Sterile dressing was applied.
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DESCRIPTION: Subxiphoid pericardial window.   A #10-blade scalpel was used to make an incision in the area of the xiphoid process.  Dissection was carried down to the level of the fascia using Bovie electrocautery.

surgery, xiphoid process, pericardium, subxiphoid pericardial window, endotracheal anesthesia, bovie electrocautery, subxiphoid pericardial, bovie, electrocautery, subxiphoid, window, pericardial,

The situation involves performing a surgical procedure known as a subxiphoid pericardial window. This type of surgery is high-stakes as it involves the pericardium, the membrane enclosing the heart, which is critical to patient survival. Additionally, surgeries inherently carry risks such as infection, bleeding, and complications from anesthesia. Given the vital nature of the affected body part and the potential for life-threatening complications, this surgical scenario is high-stakes.


Medical Specialty: Bariatrics
Sample Name: Bariatric Consult - Surgical Weight Loss - 3

PAST MEDICAL HISTORY: , Her medical conditions driving her toward surgery include hypercholesterolemia, hypertension, varicose veins, prior history of stroke.  She denies any history of cancer.  She does have a history of hepatitis which I will need to further investigate.  She complains of multiple joint pains, and heavy snoring.,PAST SURGICAL HISTORY: , Includes hysterectomy in 1995 for fibroids and varicose vein removal.  She had one ovary removed at the time of the hysterectomy as well.,SOCIAL HISTORY:,  She is a single mother of one adopted child.,FAMILY HISTORY:  ,There is a strong family history of heart disease and hypertension, as well as diabetes on both sides of her family.  Her mother is alive.  Her father is deceased from alcohol.  She has five siblings.,MEDICATIONS: , As you know she takes the following medications for her diabetes, insulin 70 units/6 units times four years, aspirin 81 mg a day, Actos 15 mg, Crestor 10 mg and CellCept 500 mg two times a day.,ALLERGIES: , She has no known drug allergies.,PHYSICAL EXAM: , She is a 54-year-old obese female.  She does not appear to have any significant residual deficits from her stroke.  There may be slight left arm weakness.,ASSESSMENT/PLAN:,  We will have her undergo routine nutritional and psychosocial assessment.  I suspect that we can significantly improve the situation with her insulin and oral hypoglycemia, as well as hypertension, with significant weight loss.  She is otherwise at increased risk for future complications given her history, and weight loss will be a good option.  We will see her back in the office once she completes her preliminary workup and submit her for approval to the insurance company.
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DESCRIPTION: Evaluation for bariatric surgery.

Evaluation for bariatric surgery.

bariatrics, evaluation for bariatric surgery, bariatric surgery, varicose veins, weight loss, varicose, veins, diabetes, bariatric, surgical, loss, surgery, hypertension, weight,

The situation involves a patient with multiple serious medical conditions, including obesity, which necessitates a bariatric surgical evaluation. Obesity-related conditions such as diabetes, hypertension, and a prior stroke increase the stakes due to potential complications from the procedure and the chronic nature of these diseases. Furthermore, the patient's history and risk profile require careful management to optimize surgical outcomes and overall health improvement. The decision to proceed with surgery can have significant impacts on her quality of life and long-term health, making it a high-stakes scenario.


Medical Specialty: Surgery
Sample Name: Anterior Cervical Discectomy - 1

PREOPERATIVE DIAGNOSIS: , Cervical spondylosis at C3-C4 with cervical radiculopathy and spinal cord compression.,POSTOPERATIVE DIAGNOSIS:,  Cervical spondylosis at C3-C4 with cervical radiculopathy and spinal cord compression.,OPERATION PERFORMED,1.  Anterior cervical discectomy of C3-C4.,2.  Removal of herniated disc and osteophytes.,3.  Bilateral C4 nerve root decompression.,4.  Harvesting of bone for autologous vertebral bodies for creation of arthrodesis.,5.  Grafting of fibular allograft bone for creation of arthrodesis.,6.  Creation of arthrodesis via an anterior technique with fibular allograft bone and autologous bone from the vertebral bodies.,7.  Placement of anterior spinal instrumentation using the operating microscope and microdissection technique.,INDICATIONS FOR PROCEDURE: , This 62-year-old man has progressive and intractable right C4 radiculopathy with neck and shoulder pain.  Conservative therapy has failed to improve the problem.  Imaging studies showed severe spondylosis of C3-C4 with neuroforaminal narrowing and spinal cord compression.,A detailed discussion ensued with the patient as to the nature of the procedure including all risks and alternatives.  He clearly understood it and had no further questions and requested that I proceed.,PROCEDURE IN DETAIL: , The patient was placed on the operating room table and was intubated using a fiberoptic technique.  The methylprednisolone spinal cord protocol was instituted with bolus and continuous infusion doses.  The neck was carefully prepped and draped in the usual sterile manner.,A transverse incision was made on a skin crease on the left side of the neck.  Dissection was carried down through the platysmal musculature and the anterior spine was exposed.  The medial borders of the longus colli muscles were dissected free from their attachments to the spine.  A needle was placed and it was believed to be at the C3-C4 interspace and an x-ray properly localized this space.  Castoff self-retaining pins were placed into the body of the C3 and C4.  Self-retaining retractors were placed in the wound keeping the blades of the retractors underneath the longus colli muscles.,The annulus was incised and a discectomy was performed.  Quite a bit of overhanging osteophytes were identified and removed.  As I worked back to the posterior lips of the vertebral body, the operating microscope was utilized.,There was severe overgrowth of spondylitic spurs.  A high-speed diamond bur was used to slowly drill these spurs away.  I reached the posterior longitudinal ligament and opened it and exposed the underlying dura.,Slowly and carefully I worked out towards the C3-C4 foramen.  The dura was extremely thin and I could see through it in several areas.  I removed the bony compression in the foramen and identified soft tissue and veins overlying the root.  All of these were not stripped away for fear of tearing this very tissue-paper-thin dura.  However, radical decompression was achieved removing all the bony compression in the foramen, out to the pedicle, and into the foramen.  An 8-mm of the root was exposed although I left the veins over the root intact.,The microscope was angled to the left side where a similar procedure was performed.,Once the decompression was achieved, a high-speed cortisone bur was used to decorticate the body from the greater posterior shelf to prevent backward graft migration.  Bone thus from the drilling was preserved for use for the arthrodesis.,Attention was turned to creation of the arthrodesis.  As I had drilled quite a bit into the bodies, I selected a large 12-mm graft and distracted the space maximally.  Under distraction the graft was placed and fit well.  An x-ray showed good graft placement.,Attention was turned to spinal instrumentation.  A Synthes Short Stature plate was used with four 3-mm screws.  Holes were drilled with all four screws were placed with pretty good purchase.  Next, the locking screws were then applied.  An x-ray was obtained which showed good placement of graft, plate, and screws.  The upper screws were near the upper endplate of C3.  The C3 vertebral body that remained was narrow after drilling off the spurs.  Rather than replace these screws and risk that the next holes would be too near the present holes I decided to leave these screws intact because their position is still satisfactory as they are below the disc endplate.,Attention was turned to closure.  A Hemovac drain was placed in the anterior vertebral body space and brought out through a separate stab wound incision in the skin.  The wound was then carefully closed in layers.  Sterile dressings were applied along with a rigid Philadelphia collar.  The operation was then terminated.,The patient tolerated the procedure well and left for the recovery room in excellent condition.  The sponge and needle counts were reported as correct and there were no intraoperative complications.,Specimens were sent to Pathology consisted of bone and soft tissue as well as C3-C4 disc material.
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DESCRIPTION: Anterior cervical discectomy, removal of herniated disc and osteophytes, bilateral C4 nerve root decompression, harvesting of bone for autologous vertebral bodies for creation of arthrodesis, grafting of fibular allograft bone for creation of arthrodesis, creation of arthrodesis via an anterior technique with fibular allograft bone and autologous bone from the vertebral bodies, and placement of anterior spinal instrumentation using the operating microscope and microdissection technique.

surgery, herniated, osteophytes, nerve root decompression, harvesting, autologous, vertebral, arthrodesis, anterior technique, anterior cervical discectomy, spinal cord compression, fibular allograft bone, creation of arthrodesis, cervical discectomy, spinal instrumentation, cord compression, vertebral body, vertebral bodies, spinal cord, bone, instrumentation, cervical, anterior, grafting, spinal, discectomy, allograft,

The described scenario is a complex surgical procedure involving the cervical spine, specifically an anterior cervical discectomy with additional steps like removal of herniated discs, osteophytes, and nerve root decompression, as well as creating an arthrodesis with spinal instrumentation. These types of surgeries generally address conditions like cervical spondylosis and spinal cord compression, which can have serious neurological implications if untreated. The stakes are high because the procedure involves operating near the spinal cord and nerve roots, which are critical structures, meaning surgical mishaps can lead to severe consequences such as paralysis or chronic pain. Therefore, the procedure demands significant precision and carries substantial risks associated with neurosurgery.


Medical Specialty: Surgery
Sample Name: Colonoscopy - 19

INDICATION: , Iron deficiency anemia.,PROCEDURE:  ,Colonoscopy with terminal ileum examination.,POSTOPERATIVE DIAGNOSIS:,  Normal examination.,WITHDRAWAL TIME: , 15 minutes.,SCOPE: , CF-H180AL.,MEDICATIONS: , Fentanyl 100 mcg and versed 10 mg.,PROCEDURE DETAIL:  ,Following the preprocedure patient assessment the procedure, goals, risks including bleeding, perforation, missed polyp rate as well as side effects of medications and alternatives were reviewed.  Questions were answered.  Pause preprocedure was performed.,Following titrated intravenous sedation the flexible video endoscope was introduced into the rectum and advanced to the cecum without difficulty.  The ileocecal valve looked normal.  Preparation was fair allowing examination of 85% of mucosa after washing and cleaning with tap water through the scope.  The terminal ileum was intubated through the ileocecal valve for a 5 cm extent.  Terminal ileum mucosa looked normal.,Then the scope was withdrawn while examining the mucosa carefully including the retroflexed views of the rectum.  No polyp, no diverticulum and no bleeding source was identified.,The patient was assessed upon completion of the procedure.  Okay to discharge once criteria met.  ,RECOMMENDATIONS:,  Follow up with primary care physician.
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DESCRIPTION: Colonoscopy with terminal ileum examination.   Iron deficiency anemia.  Following titrated intravenous sedation the flexible video endoscope was introduced into the rectum and advanced to the cecum without difficulty.

surgery, polyp, endoscope, mucosa, iron deficiency anemia, ileocecal valve, terminal ileum, colonoscopy, anemia, rectum, ileum

The procedure described is a colonoscopy, which is a routine and common medical procedure used to diagnose issues in the colon and rectum. While it carries some risks such as bleeding and perforation, these are generally low. The procedure was carried out without complications, as noted by the normal findings and the absence of polyps, diverticula, or bleeding. Although it is an important procedure for the patient's diagnosis and future treatment, in medical terms, this situation does not involve immediate life-or-death decisions, and there were normal postoperative findings.


Medical Specialty: Surgery
Sample Name: Bronchoscopy Brushings

OPERATIVE PROCEDURE:,  Bronchoscopy brushings, washings and biopsies.,HISTORY: , This is a 41-year-old woman admitted to Medical Center with a bilateral pulmonary infiltrate, immunocompromise.,INDICATIONS FOR THE PROCEDURE:,  Bilateral infiltrates, immunocompromised host, and pneumonia.,Prior to procedure, the patient was intubated with 8-French ET tube orally by Anesthesia due to her profound hypoxemia and respiratory distress.,DESCRIPTION OF PROCEDURE: , Under MAC and fluoroscopy, fiberoptic bronchoscope was passed through the ET tube.,ET tube was visualized approximately 2 cm above the carina.  Fiberoptic bronchoscope subsequently was passed through the right lower lobe area and transbronchial biopsies under fluoroscopy were done from the right lower lobe x3 as well as the brushings were obtained and the washings.  The patient tolerated the procedure well.  Postprocedure, the patient is to be placed on a ventilator as well as postprocedure chest x-ray pending.  Specimens are sent for immunocompromise panel including PCP stains.,POSTPROCEDURE DIAGNOSIS:,  Pneumonia, infiltrates.
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DESCRIPTION: Bronchoscopy brushings, washings and biopsies.  Patient with a bilateral infiltrates, immunocompromised host, and pneumonia.

surgery, mac, fluoroscopy, fiberoptic bronchoscope, bronchoscopy brushings, fiberoptic, bronchoscope, bronchoscopy, biopsies, pneumonia, immunocompromised

The medical situation involves a critically ill patient who is immunocompromised and has severe pneumonia requiring intubation and mechanical ventilation. The bronchoscopy procedure, while routine in nature, is being performed to diagnose and manage potentially life-threatening conditions in an immunocompromised patient, which adds to the complexity and urgency. Given the patient's fragile condition, the stakes are relatively high as both the procedure and the subsequent medical management decisions are critical to the patient's recovery and survival.


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

REASON FOR CONSULT: , Medical management, status post left total knee arthroplasty.,PAST MEDICAL HISTORY:,1.  Polyarthritis.,2.  Acromegaly.,3.  Hypothyroidism.,4.  Borderline hypertension.,5.  Obesity.,PAST SURGICAL HISTORY: , Hernia repair, resection of tumor, right thumb arthrodesis, carpal tunnel decompression, bilateral hip replacement, right total knee replacement about 2 months ago, open reduction of left elbow fracture.,REVIEW OF SYSTEMS:,CONSTITUTIONAL SYMPTOMS:  No fever or recent general malaise.,ENT:  Not remarkable.,RESPIRATORY:  No cough or shortness of breath.,CARDIOVASCULAR:  The patient denies any heart problems.  No orthopnea.  No palpitations.  No syncopal episodes.,GASTROINTESTINAL:  No nausea.  No vomiting.  No history of GI bleed.,GENITOURINARY:  No dysuria, no hematuria.,ENDOCRINE:  The patient is status post pituitary tumor resection and is on supplemental hormone.,MEDICATIONS:  Depo-Testosterone 200 mg IM q.3 weekly, prednisone 1 tablet p.o. daily, octreotide IM on a monthly basis, morphine extended release 50 mg p.o. b.i.d., Synthroid 100 mcg p.o. daily, desmopressin 1 tablet p.o. every bedtime, aspirin/oxycodone on a p.r.n. basis, aspirin on p.r.n. basis.,ALLERGIES: , IBUPROFEN AND TYLENOL.,SOCIAL HISTORY: , The patient does not smoke nor drink alcohol.,FAMILY HISTORY: , Noncontributory.,PHYSICAL EXAMINATION,GENERAL:  Obese, 57-year-old gentleman, not in acute distress.,VITAL SIGNS:  Blood pressure of 105/55, pulse is 90.  He is afebrile.  O2 saturation is 95% on room air.,HEAD AND NECK:  Face symmetrical.  Cranial nerves are intact.  No distended neck veins.  No palpable neck masses.,CHEST:  Clear to auscultation.  No wheezing.  No crepitations.,CARDIOVASCULAR:  First and second heart sounds were heard.  No murmur was appreciated.,ABDOMEN:  Benign.,EXTREMITIES:  The left knee is in closed dressing.  The lower extremities are still numb from spinal anesthesia.,ASSESSMENT AND PLAN:,1.  Polyarthritis, status post left total knee replacement.  The patient tolerated the procedure well.,2.  Acromegaly, status post pituitary resection.  Continue supplemental hormones.,3.  Borderline hypertension, blood pressure is under control with monitoring.,4.  Deep venous thrombosis prophylaxis as per surgeon.,5.  Anemia due to repeated blood loss with monitor hemoglobin and hematocrit.
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DESCRIPTION: Medical management, status post left total knee arthroplasty.

The patient, a 57-year-old man with a complex medical history including polyarthritis, acromegaly, and hypothyroidism, is being assessed following a left total knee arthroplasty. The situation requires careful medical management due to the patient's multiple comorbidities and the recent surgical procedure. However, the patient's vital signs are stable, and there are no acute distress signals or severe complications noted. Regular monitoring is needed, especially due to the risk of anemia and the need for DVT prophylaxis. While these are important considerations, the case does not involve immediate life-threatening conditions, thus not qualifying as extremely high-stakes.


Medical Specialty: Surgery
Sample Name: TAH & Salpingo-oophorectomy & Lysis of Adhesions

PREOPERATIVE DIAGNOSES:,1.  Chronic pelvic pain.,2.  Endometriosis.,3.  Prior right salpingo-oophorectomy.,4.  History of intrauterine device perforation and exploratory surgery.,POSTOPERATIVE DIAGNOSES:,1.  Endometriosis.,2.  Interloop bowel adhesions.,PROCEDURE PERFORMED:,1.  Total abdominal hysterectomy (TAH).,2.  Left salpingo-oophorectomy.,3.  Lysis of interloop bowel adhesions.,ANESTHESIA:,  General.,ESTIMATED BLOOD LOSS:  ,400 cc.,FLUIDS: , 2300 cc of lactated Ringers, as well as lactated Ringers for intraoperative irrigation.,URINE: , 500 cc of clear urine output.,INTRAOPERATIVE FINDINGS: , The vulva and perineum are without lesions.  On bimanual exam, the uterus was enlarged, movable, and anteverted.  The intraabdominal findings revealed normal liver margin, kidneys, and stomach upon palpation.  The uterus was found to be normal in size with evidence of endometriosis on the uterus.  The right ovary and fallopian tube were absent.  The left fallopian tube and ovary appeared normal with evidence of a small functional cyst.  There was evidence of left adnexal adhesion to the pelvic side wall which was filmy, unable to be bluntly dissected.  There were multiple interloop bowel adhesions that were filmy in nature noted.,The appendix was absent.  There did appear to be old suture in a portion of the bowel most likely from a prior procedure.,INDICATIONS: , This patient is a 45-year-old African-American gravida7, para3-0-0-3, who is here for definitive treatment of chronic pelvic pain with a history of endometriosis.  She did have a laparoscopic ablation of endometriosis on a laparoscopy and also has a history of right salpingo-oophorectomy.  She has tried Lupron and did stop secondary to the side effects.,PROCEDURE IN DETAIL: , After informed consent was obtained in layman's terms, the patient was taken back to the Operating Suite and placed under general anesthesia.  She was then prepped and draped in the sterile fashion and placed in the dorsal supine position.  An indwelling Foley catheter was placed.  With the skin knife, an incision was made removing the old cicatrix.  A Bovie was used to carry the tissue through to the underlying layer of the fascia which was incised in the midline and extended with the Bovie.  The rectus muscle was then sharply and bluntly dissected off the superior aspect of the rectus fascia in the superior as well as the inferior aspect using the Bovie.  The rectus muscle was then separated in the midline using a hemostat and the peritoneum was entered bluntly.  The peritoneal incision was then extended superiorly and inferiorly with Metzenbaum scissors with careful visualization of the bladder.  At this point, the intraabdominal cavity was manually explored and the above findings were noted.  A Lahey clamp was then placed on the fundus of the uterus and the uterus was brought to the surgical field.  The bowel was then packed with moist laparotomy sponges.  Prior to this, the filmy adhesions leftover were taken down.  At this point, the left round ligament was identified, grasped with two hemostats, transected, and suture ligated with #0 Vicryl.  At this point, the broad ligament was dissected down and the lost portion of the bladder flap was created.  The posterior aspect of the peritoneum was also dissected.  At this point, the infundibulopelvic ligament was isolated and three tie of #0 Vicryl was used to isolate the pedicle.  Two hemostats were then placed across the pedicle and this was transected with the scalpel.  This was then suture ligated in Heaney fashion.  The right round ligament was then identified and in the similar fashion, two hemostats were placed across the round ligament and using the Mayo scissors the round ligament was transected and dissected down the broad ligament to create the bladder flap anteriorly as well as dissect the posterior peritoneum and isolate the round ligament.  This was then ligated with three tie of #0 Vicryl.  Also incorporated in this was the remnant from the previous right salpingo-oophorectomy.  At this point, the bladder flap was further created with sharp dissection as well as the moist Ray-Tech to push the bladder down off the anterior portion of the cervix.,The left uterine artery was then skeletonized and a straight Heaney was placed.  In a similar fashion, the contralateral uterine artery was skeletonized and straight Heaney clamp was placed.  These ligaments bilaterally were transected and suture ligated in a left Heaney stitch.  At this point, curved Masterson was used to incorporate the cardinal ligament complex, thus was transected and suture ligated.  Straight Masterson was then used to incorporate the uterosacrals bilaterally and this was also transected and suture ligated.  Prior to ligating the uterine arteries, the uterosacral arteries were tagged bilaterally with #0 Vicryl.  At this point, the roticulator was placed across the vaginal cuff and snug underneath the entire cervix.  The roticulator was then clamped and removed and the staple line was in place.  This was found to be hemostatic.  A suture was then placed through each cuff angle bilaterally and cardinal ligament complex was found to be fixed to each apex bilaterally.  At this point, McCall culdoplasty was performed with an #0 Vicryl incorporating each uterosacral as well as the posterior peritoneum.  There did appear to be good support on palpation.  Prior to this, the specimen was handed off and sent to pathology.  At this point, there did appear to be small amount of oozing at the right peritoneum.  Hemostasis was obtained using a #0 Vicryl in two single stitches.  Good hemostasis was then obtained on the cuff as well as the pedicles.  Copious irrigation was performed at this point with lactate Ringers.  The round ligaments were then incorporated into the cuff bilaterally.  Again, copious amount of irrigation was performed and good hemostasis was obtained.  At this point, the peritoneum was reapproximated in a single interrupted stitch on the left and right lateral aspects to cover each pedicle bilaterally.  At this point, the bowel packing as well as moist Ray-Tech was removed and while re-approximating the bowel it was noted that there were multiple interloop bowel adhesions which were taken down using the Metzenbaum scissors with good visualization of the underlying bowel.  Good hemostasis was obtained of these sites as well.  The sigmoid colon was then returned to its anatomic position and the omentum as well.  The rectus muscle was then reapproximated with two interrupted sutures of #2-0 Vicryl.  The fascia was then reapproximated with #0 Vicryl in a running fashion from lateral to medial meeting in the midline.  The Scarpa's fascia was then closed with #3-0 plain in a running suture.  The skin was then re-approximated with #4-0 undyed Vicryl in a subcuticular closure.  This was dressed with an Op-Site.  The patient tolerated the procedure well.  The sponge, lap, and needle were correct x2.  After the procedure, the patient was extubated and brought out of general anesthesia.  She will go to the floor where she will be followed postoperatively in the hospital.
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DESCRIPTION: Total abdominal hysterectomy (TAH), left salpingo-oophorectomy, lysis of interloop bowel adhesions.  Chronic pelvic pain, endometriosis, prior right salpingo-oophorectomy, history of intrauterine device perforation and exploratory surgery.

surgery, chronic pelvic pain, endometriosis, intrauterine device, exploratory, abdominal hysterectomy, tah, total abdominal hysterectomy, lysis of interloop bowel adhesions, salpingo oophorectomy, bowel, ligament, adhesions, interloop, hemostasis, uterus, salpingo, oophorectomy,

The scenario involves a complex surgical procedure, including a total abdominal hysterectomy, left salpingo-oophorectomy, and lysis of bowel adhesions, as treatment for chronic pelvic pain and endometriosis. Surgery inherently carries risks such as bleeding, infection, and potential damage to surrounding organs. The patient has a history of multiple significant medical issues, and any complications during the surgery could have serious consequences on her health and quality of life. However, it is a standard procedure performed with a clear indication, and the situation described suggests it was well-managed, reducing immediate stakes. Nevertheless, the stakes are considerable due to potential risks and the critical nature of a successful outcome for patient well-being.


Medical Specialty: Gastroenterology
Sample Name: Colonoscopy - 21

OPERATIVE PROCEDURES: , Colonoscopy and biopsies, epinephrine sclerotherapy, hot biopsy cautery, and snare polypectomy.,PREOPERATIVE DIAGNOSES:,1.  Colon cancer screening.,2.  Family history of colon polyps.,POSTOPERATIVE DIAGNOSES:,1.  Multiple colon polyps (5).,2.  Diverticulosis, sigmoid colon.,3.  Internal hemorrhoids.,ENDOSCOPE USED: , EC3870LK.,BIOPSIES:  ,Biopsies taken from all polyps.  Hot biopsy got applied to one.  Epinephrine sclerotherapy and snare polypectomy applied to four polyps.,ANESTHESIA: , Fentanyl 75 mcg, Versed 6 mg, and glucagon 1.5 units IV push in divided doses.  Also given epinephrine 1:20,000 total of 3 mL.,The patient tolerated the procedure well.,PROCEDURE:  ,The patient was placed in left lateral decubitus after appropriate sedation.  Digital rectal examination was done, which was normal.  Endoscope was introduced and passed through a rather spastic tortuous sigmoid colon with multiple diverticula seen all the way through transverse colon where about 1 cm x 1 cm sessile polyp was seen.  It was biopsied and then in piecemeal fashion removed using snare polypectomy after base was infiltrated with epinephrine.  Pedunculated polyp next to it was hard to see and there was a lot of peristalsis.  The scope then was advanced through rest of the transverse colon to ascending colon and cecum.  Terminal ileum was briefly reviewed, appeared normal and so did cecum after copious amount of fecal material was irrigated out.  Ascending colon was unremarkable.  At hepatic flexure may be proximal transverse colon, there was a sessile polyp about 1.2 cm x 1 cm that was removed in the same manner with a biopsy taken, base infiltrated with epinephrine and at least two passes of snare polypectomy and subsequent hot biopsy cautery removed to hold polypoid tissue, which could be seen.  In transverse colon on withdrawal and relaxation with epinephrine, an additional 1 mm to 2 mm sessile polyp was removed by hot biopsy.  Then in the transverse colon, additional larger polyp about 1.3 cm x 1.2 cm was removed in piecemeal fashion again with epinephrine, sclerotherapy, and snare polypectomy.  Subsequently pedunculated polyp in distal transverse colon near splenic flexure was removed with snare polypectomy.  The rest of the splenic flexure and descending colon were unremarkable.  Diverticulosis was again seen with almost constant spasm despite of glucagon.  Sigmoid colon did somewhat hinder the inspection of that area.  Rectum, retroflexion posterior anal canal showed internal hemorrhoids moderate to large.  Excess of air insufflated was removed.  The endoscope was withdrawn.,PLAN: , Await biopsy report.  Pending biopsy report, recommendation will be made when the next colonoscopy should be done at least three years perhaps sooner besides and due to multitude of the patient's polyps.
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DESCRIPTION: Colonoscopy and biopsies, epinephrine sclerotherapy, hot biopsy cautery, and snare polypectomy.  Colon cancer screening.  Family history of colon polyps.

gastroenterology, colon cancer, colon polyps, snare polypectomy, cautery, epinephrine sclerotherapy, transverse colon, polypectomy, colonoscopy, sigmoid, endoscope, sclerotherapy, epinephrine, biopsy,

The situation involves a medical procedure, colonoscopy, that is routine for cancer screening, especially given the patient's family history of colon polyps, which can increase the risk of developing colorectal cancer. However, while the procedure is relatively routine and performed safely, it carries heightened importance due to the potential for early detection of cancerous or precancerous polyps. Moreover, multiple polyps were found and removed, emphasizing the need for careful monitoring and follow-up, potentially affecting the patient’s long-term health. Thus, while the procedure itself is standard, the circumstances and findings elevate its stakes.


Medical Specialty: Surgery
Sample Name: Delivery Note - 4

DELIVERY NOTE: , The patient came in around 0330 hours in the morning on this date 12/30/08 in early labor and from a closed cervix very posterior yesterday; she was 3 cm dilated.  Membranes ruptured this morning by me with some meconium.  An IUPC was placed.  Some Pitocin was started because the contractions were very weak.  She progressed in labor throughout the day.  Finally getting the complete at around 1530 hours and began pushing.  Pushed for about an hour and a half when she was starting to crown.  The Foley was already removed at some point during the pushing.  The epidural was turned down by the anesthesiologist because she was totally numb.  She pushed well and brought the head drown crowning, at which time I arrived and setting her up delivery with prepping and draping.  She pushed well delivering the head and DeLee suctioning was carried out on the perineum because of the meconium even though good amount of amnioinfusion throughout the day was completed.  With delivery of the head, I could see the perineum tear and after delivery of the baby and doubly clamping of the cord having baby off to RT in attendance.  Exam revealed a good second-degree tear ascended a little bit up higher in the vagina and a little off to the right side but rectum sphincter were intact, although I cannot see good fascia around the sphincter anteriorly.  The placenta separated with some bleeding seen and was assisted expressed and completely intact.  Uterus firmed up well with IV pit.  Repair of the tear with 2-0 Vicryl stitches and a 3-0 Vicryl in a subcuticular like area just above the rectum and the perineum was performed using a little local anesthesia to top up with the epidural.  Once this was complete, mom and baby doing well.  Baby was a female infant.  Apgars 8 and 9.
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DESCRIPTION: She progressed in labor throughout the day.  Finally getting the complete and began pushing.  Pushed for about an hour and a half when she was starting to crown.

surgery, iupc, meconium, pitocin, epidural, rectum, sphincter, labor, perineum, pushed, deliveryNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

The information provided describes a detailed account of a labor and delivery process, including several medical interventions such as membrane rupture, induction of labor with Pitocin, use of an intrauterine pressure catheter (IUPC), an epidural for pain management, and repair of a perineal tear. The successful outcome, with both mother and baby doing well, suggests proper management of potentially complicated situations such as meconium-stained amniotic fluid and perineal tearing. Childbirth inherently carries risk to both mother and baby, and successful navigation of these risks is crucial. However, it's described as being managed competently. Therefore, while the situation is serious and requires expert management, it's a routine high-stakes situation in medical practice.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Hysterectomy - Discharge Summary

ADMISSION DIAGNOSES:,1.  Menorrhagia.,2.  Uterus enlargement.,3.  Pelvic pain.,DISCHARGE DIAGNOSIS: , Status post vaginal hysterectomy.,COMPLICATIONS: , None.,BRIEF HISTORY OF PRESENT ILLNESS: , This is a 36-year-old, gravida 3, para 3 female who presented initially to the office with abnormal menstrual bleeding and increase in flow during her period.  She also had symptoms of back pain, dysmenorrhea, and dysuria.  The symptoms had been worsening over time.  The patient was noted also to have increasing pelvic pain over the past 8 months and she was noted to have uterine enlargement upon examination.,PROCEDURE:,  The patient underwent a total vaginal hysterectomy.,HOSPITAL COURSE:  ,The patient was admitted on 09/04/2007 to undergo total vaginal hysterectomy.  The procedure preceded as planned without complication.  Uterus was sent for pathologic analysis.  The patient was monitored in the hospital, 2 days postoperatively.  She recovered quite well and vitals remained stable.,Laboratory studies, H&H were followed and appeared stable on 09/05/2007 with hemoglobin of 11.2 and hematocrit of 31.8.,The patient was ready for discharge on Monday morning of 09/06/2007.,LABORATORY FINDINGS: , Please see chart for full studies during admission.,DISPOSITION:  ,The patient was discharged to home in stable condition.  She was instructed to follow up in the office postoperatively.
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DESCRIPTION: The patient underwent a total vaginal hysterectomy.

obstetrics / gynecology, menorrhagia, uterus enlargement, pelvic pain, total vaginal hysterectomy, vaginal hysterectomy, uterus, vaginal, hysterectomy,

The case involves a total vaginal hysterectomy, a significant surgical procedure. However, the surgery was completed without complications and the patient recovered well post-operatively, was stable, and was discharged safely. Given the absence of complications and stable recovery, the situation is not extremely high-stakes, yet it involves major surgery which carries inherent risks.


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

Medical Specialty: Radiology
Sample Name: Echocardiogram - 3

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

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

The echocardiogram findings indicate several heart conditions including biatrial enlargement, a mildly dilated left ventricle with reduced ejection fraction, mitral regurgitation, and mild pulmonary hypertension. While these conditions suggest a certain degree of cardiac dysfunction that requires medical attention, they are not immediately life-threatening. The patient is likely being monitored and treated for coronary artery disease, which is a known risk factor for serious cardiac events. However, this is a routine diagnostic scenario that involves an ongoing management plan, rather than an acute, high-stakes emergency situation.


Medical Specialty: Surgery
Sample Name: Teeth Extraction & I&D

PREOPERATIVE DIAGNOSES,1.  Carious teeth #2, #5, #12, #15, #18, #19, and #31.,2.  Left mandibular vestibular abscess.,POSTOPERATIVE DIAGNOSES,1.  Carious teeth #2, #5, #12, #15, #18, #19, and #31.,2.  Left mandibular vestibular abscess.,PROCEDURE,1.  Extraction of teeth #2.  #5, #12, #15, #18, #19, #31.,2.  Incision and drainage (I&D) of left mandibular vestibular abscess adjacent to teeth #18 and #19.,ANESTHESIA:,  General nasotracheal.,COMPLICATIONS: , None.,DRAIN:,  Quarter-inch Penrose drain place in left mandibular vestibule adjacent to teeth #18 and #19, secured with 3-0 silk suture.,CONDITION:,  The patient was taken to the PACU in stable condition.,INDICATION:,  Patient is a 32-year-old female who was admitted yesterday 03/04/10 with left facial swelling and a number of carious teeth which were also abscessed particularly those on the lower left and this morning, the patient was brought to the operating room for extraction of the carious teeth and incision and drainage of left vestibular abscess.,DESCRIPTION OF PROCEDURE:,  Patient was brought to the operating room, placed on the table in a supine position, and after demonstration of an adequate plane of general anesthesia via the nasotracheal route, patient was prepped and draped in the usual fashion for an intraoral procedure.  A gauze throat pack was placed and local anesthetic was administered in all four quadrants, a total of 6.8 mL of lidocaine 2% with 1:100,000 epinephrine, and 3.6 mL of Marcaine 0.5% with 1:200,000 epinephrine.  The area in the left vestibular area adjacent to the teeth #18 and #19 was aspirated with 5 cc syringe with an 18-guage needle and approximately 1 mL of purulent material was aspirated.  This was placed on the culture medium in the aerobic and anaerobic culture tubes and the tubes were then sent to the lab.  An incision was then made in the left mandibular vestibule adjacent to teeth #18 and #19.  The area was bluntly dissected with a curved hemostat and a small amount of approximately 3 mL of purulent material was drained.  Penrose drain was then placed using a curved hemostat.  The drain was secured with 3-0 silk suture.  The extraction of the teeth was then begun on the left side removing teeth #12, #15, #18 and #19 with forceps extraction, then moving to the right side teeth #2, #5, and #31 were removed with forceps extraction uneventfully.  After completion of the procedure, the throat pack was removed, the pharynx was suctioned.  The anesthesiologist then placed an orogastric tube and suctioned approximately 10 cc of stomach contents with the nasogastric tube.  The nasogastric tube was then removed.  Patient was then extubated and taken to the PACU in stable condition.
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DESCRIPTION: Extraction of teeth.  Incision and drainage (I&D) of left mandibular vestibular abscess adjacent to teeth #18 and #19.

surgery, mandibular, vestibular, abscess, throat pack, purulent material, forceps extraction, nasogastric tube, carious teeth, incision, teeth, nasogastric, carious, extraction

The procedures described involve dental surgery for the extraction of multiple carious teeth and the incision and drainage of an abscess in the left mandibular vestibular area. These procedures are invasive and utilize general anesthesia, implying a higher degree of risk compared to minor medical procedures. However, they are routine in nature for oral surgeons and did not result in complications, as the patient was stable post-operation. This places the situation at a moderate level of stakes due to the surgical and anesthetic components.


Medical Specialty: Surgery
Sample Name: Bilateral Carotid Cerebral Angiogram

PREOPERATIVE DIAGNOSES:,1.  Carotid artery occlusive disease.,2.  Peripheral vascular disease.,POSTOPERATIVE DIAGNOSES:,1.  Carotid artery occlusive disease.,2.  Peripheral vascular disease.,OPERATIONS PERFORMED:,1.  Bilateral carotid cerebral angiogram.,2.  Right femoral-popliteal angiogram.,FINDINGS: , The right carotid cerebral system was selectively catheterized and visualized.  The right internal carotid artery was found to be very tortuous with kinking in its cervical portions, but no focal stenosis was noted.  Likewise, the intracranial portion of the right internal carotid artery showed no significant disease nor did the right middle cerebral artery.,The left carotid cerebral system was selectively catheterized and visualized.  The cervical portion of the left internal carotid artery showed a 30 to 40% stenosis with small ulcer crater present.  The intracranial portion of the left internal carotid artery showed no significant disease nor did the left middle cerebral artery.,Visualization of the right lower extremity showed no significant disease.,PROCEDURE: , With the patient in supine position under local anesthesia plus intravenous sedation, the groin areas were prepped and draped in a sterile fashion.,The common femoral artery was punctured in a routine retrograde fashion and a 5-French introducer sheath was advanced under fluoroscopic guidance.  A catheter was then placed in the aortic arch and the right and left common carotid arteries were then selectively catheterized and visualized as described above.,Following completion of the above, the catheter and introducer sheath were removed.  Heparin had been initially given, which was reversed with protamine.  Firm pressure was held over the puncture site for 20 minutes, followed by application of a sterile Coverlet dressing and sandbag compression.,The patient tolerated the procedure well throughout.
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DESCRIPTION: Bilateral carotid cerebral angiogram and right femoral-popliteal angiogram.

surgery, femoral-popliteal angiogram, carotid cerebral angiogram, internal carotid artery, carotid artery, angiogram, carotid, cerebral, artery,

This scenario involves a diagnostic medical procedure, specifically imaging of the carotid and femoral arteries, which is crucial for managing vascular diseases. Carotid artery disease can lead to serious conditions like strokes, and peripheral vascular disease can lead to serious complications if not managed properly. The correct interpretation of the angiogram findings can significantly impact patient management and outcomes. Additionally, the procedure involves risks such as bleeding or stroke, though these are generally low with proper technique. Therefore, while it's a diagnostic procedure, the implications for treatment and potential complications contribute to its significance.


Medical Specialty: Podiatry
Sample Name: MRI Foot - 2

EXAM:,MRI RIGHT FOOT,CLINICAL:,Pain and swelling in the right foot.,FINDINGS: ,Obtained for second opinion interpretation is an MRI examination performed on 11-04-05.,There is a transverse fracture of the anterior superior calcaneal process of the calcaneus. The fracture is corticated however and there is an active marrow stress phenomenon. There is a small ganglion measuring approximately 8 x 5 x 5mm in size extending along the bifurcate ligament.,There is no substantial joint effusion of the calcaneocuboid articulation. There is minimal interstitial edema involving the short plantar calcaneal cuboid ligament.,Normal plantar calcaneonavicular spring ligament.,Normal talonavicular articulation.,There is minimal synovial fluid within the peroneal tendon sheaths.,Axial imaging of the ankle has not been performed orthogonal to the peroneal tendon distal to the retromalleolar groove. The peroneus brevis tendon remains intact extending to the base of the fifth metatarsus. The peroneus longus tendon can be identified in its short axis extending to its distal plantar insertion upon the base of the first metatarsus with minimal synovitis.,There is minimal synovial fluid within the flexor digitorum longus and flexor hallucis longus tendon sheath with pooling of the fluid in the region of the knot of Henry.,There is edema extending along the deep surface of the extensor digitorum brevis muscle.,Normal anterior, subtalar and deltoid ligamentous complex.,Normal naviculocuneiform, intercuneiform and tarsometatarsal articulations.,The Lisfranc’s ligament is intact.,The Achilles tendon insertion has been excluded from the field-of-view.,Normal plantar fascia and intrinsic plantar muscles of the foot.,There is mild venous distention of the veins of the foot within the tarsal tunnel.,There is minimal edema of the sinus tarsus. The lateral talocalcaneal and interosseous talocalcaneal ligaments are normal.,Normal deltoid ligamentous complex.,Normal talar dome and no occult osteochondral talar dome defect.,IMPRESSION:,Transverse fracture of the anterior calcaneocuboid articulation with cortication and cancellous marrow edema.,Small ganglion intwined within the bifurcate ligament.,Interstitial edema of the short plantar calcaneocuboid ligament.,Minimal synovitis of the peroneal tendon sheaths but no demonstrated peroneal tendon tear.,Minimal synovitis of the flexor tendon sheaths with pooling of fluid within the knot of Henry.,Minimal interstitial edema extending along the deep surface of the extensor digitorum brevis muscle.
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DESCRIPTION: Pain and swelling in the right foot.

Pain and swelling in the right foot.

The MRI report indicates a fracture and some soft tissue changes, such as edema and a ganglion. While these findings can cause pain and may need treatment, they are not life-threatening or exceptionally urgent in the context of medical situations that could occur. The management of these findings typically involves conservative treatment and possibly surgical intervention, but it does not represent a critical or life-or-death scenario. Thus, the situation does not appear to be high-stakes compared to other medical emergencies.


Medical Specialty: Surgery
Sample Name: Flexible Fiberoptic Bronchoscopy -1

POSTOPERATIVE DIAGNOSIS:,  Mild tracheobronchitis with history of granulomatous disease and TB, rule out active TB/miliary TB.,PROCEDURE PERFORMED:,  Flexible fiberoptic bronchoscopy diagnostic with:,a.  Right middle lobe bronchoalveolar lavage.,b.  Right upper lobe bronchoalveolar lavage.,c.  Right lower lobe transbronchial biopsies.,COMPLICATIONS:,  None.,Samples include bronchoalveolar lavage of the right upper lobe and right middle lobe and transbronchial biopsies of the right lower lobe.,INDICATION:  ,The patient with a history of TB and caseating granulomata on open lung biopsy with evidence of interstitial lung disease and question tuberculosis.,PROCEDURE:,  After obtaining an informed consent, the patient was brought to the Bronchoscopy Suite with appropriate isolation related to ______ precautions.  The patient had appropriate oxygen, blood pressure, heart rate, and respiratory rate monitoring applied and monitored continuously throughout the procedure.  2 liters of oxygen via nasal cannula was applied to the nasopharynx with 100% saturations achieved.  Topical anesthesia with 10 cc of 4% Xylocaine was applied to the right nares and oropharynx.  Subsequent to this, the patient was premedicated with 50 mg of Demerol and then Versed 1 mg sequentially for a total of 2 mg.  With this, adequate consciousness sedation was achieved.  3 cc of 4% viscous Xylocaine was applied to the right nares.  The bronchoscope was then advanced through the right nares into the nasopharynx and oropharynx.,The oropharynx and larynx were well visualized and showed mild erythema, mild edema, otherwise negative.,There was normal vocal cord motion without masses or lesions.  Additional topical anesthesia with 2% Xylocaine was applied to the larynx and subsequently throughout the tracheobronchial tree for a total of 18 cc.  The bronchoscope was then advanced through the larynx into the trachea.  The trachea showed mild evidence of erythema and moderate amounts of clear frothy secretions.  These were suctioned clear.  The bronchoscope was then advanced through the carina, which was sharp.  Then advanced into the left main stem and each segment, subsegement in the left upper lingula and lower lobe was visualized.  There was mild tracheobronchitis with mild friability throughout.  There was modest amounts of white secretion.  There were no other findings including evidence of mass, anatomic distortions, or hemorrhage.  The bronchoscope was subsequently withdrawn and advanced into the right mainstem.  Again, each segment and subsegment was well visualized.  The right upper lobe anatomy showed some segmental distortion with dilation and irregularities both at the apical region as well as in the subsegments of the anteroapical and posterior segments.  No specific masses or other lesions were identified throughout the tracheobronchial tree on the right.  There was mild tracheal bronchitis with friability.  Upon coughing, there was punctate hemorrhage.  The bronchoscope was then advanced through the bronchus intermedius and the right middle lobe and right lower lobe.  These again had no other anatomic lesions identified.  The bronchoscope was then wedged in the right middle lobe and bronchoalveolar samples were obtained.  The bronchoscope was withdrawn and the area was suctioned clear.  The bronchoscope was then advanced into the apical segment of the right upper lobe and the bronchioalveolar lavage again performed.  Samples were taken and the bronchoscope was removed suctioned the area clear.  The bronchoscope was then re-advanced into the right lower lobe and multiple transbronchial biopsies were taken under fluoroscopic guidance in the posterior and lateral segments of the right lower lobe.  Minimal hemorrhage was identified and suctioned clear without difficulty.  The bronchoscope was then withdrawn to the mainstem.  The area was suctioned clear.  Fluoroscopy revealed no evidence of pneumothorax.  The bronchoscope was then withdrawn.  The patient tolerated the procedure well without evidence of desaturation or complications.
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DESCRIPTION: Flexible fiberoptic bronchoscopy diagnostic with right middle and upper lobe lavage and lower lobe transbronchial biopsies.  Mild tracheobronchitis with history of granulomatous disease and TB, rule out active TB/miliary TB.

surgery, bronchoalveolar, lavage, lobe, tracheobronchitis, granulomatous, miliary tb, tb, flexible fiberoptic bronchoscopy, bronchoscope, flexible, fiberoptic, transbronchial, biopsies, bronchoscopy, oropharynx,

The situation involves a diagnostic procedure performed on a patient with a history of tuberculosis (TB) and granulomatous disease, which inherently carries some risk due to the patient's medical history and the invasive nature of the procedure. However, the procedure was conducted successfully without complications, indicating good management and preparation. While the results of the procedure, such as ruling out active TB, are crucial for the patient's treatment plan, the immediate situation lacks the urgency or life-threatening elements typically associated with extremely high-stakes scenarios. The stakes are moderate because the procedure helps determine necessary medical treatments, but there was no immediate negative outcome reported.


Medical Specialty: Orthopedic
Sample Name: Total Knee Arthoplasty - Right - 1

PREOPERATIVE DIAGNOSIS:,  Severe degenerative joint disease of the right knee.,POSTOPERATIVE DIAGNOSIS: , Severe degenerative joint disease of the right knee.,PROCEDURE:,  Right total knee arthroplasty using a Biomet cemented components, 62.5-mm right cruciate-retaining femoral component, 71-mm Maxim tibial component, and 12-mm polyethylene insert with 31-mm patella.  All components were cemented with Cobalt G.,ANESTHESIA:,  Spinal.,ESTIMATED BLOOD LOSS: , Minimal.,TOURNIQUET TIME: , Less than 60 minutes.,The patient was taken to the Postanesthesia Care Unit in stable condition.  The patient tolerated the procedure well.,INDICATIONS:  ,The patient is a 51-year-old female complaining of worsening right knee pain.  The patient had failed conservative measures and having difficulties with her activities of daily living as well as recurrent knee pain and swelling.  The patient requested surgical intervention and need for total knee replacement.,All risks, benefits, expectations, and complications of surgery were explained to her in great detail and she signed informed consent.  All risks including nerve and vessel damage, infection, and revision of surgery as well as component failure were explained to the patient and she did sign informed consent.  The patient was given antibiotics preoperatively.,PROCEDURE DETAIL:  ,The patient was taken to the operating suite and placed in supine position on the operating table.  She was placed in the seated position and a spinal anesthetic was placed, which the patient tolerated well.  The patient was then moved to supine position again and a well-padded tourniquet was placed on the right thigh.  Right lower extremity was prepped and draped in sterile fashion.  All extremities were padded prior to this.,The right lower extremity, after being prepped and draped in the sterile fashion, the tourniquet was elevated and maintained for less than 60 minutes in this case.  A midline incision was made over the right knee and medial parapatellar arthrotomy was performed.  Patella was everted.  The infrapatellar fat pad was incised and medial and lateral meniscectomy was performed and the anterior cruciate ligament was removed.  The posterior cruciate ligament was intact.,There was severe osteoarthritis of the lateral compartment on the lateral femoral condyle as well as mild-to-moderate osteoarthritis in the medial femoral compartment as well severe osteoarthritis along the patellofemoral compartment.  The medial periosteal tissue on the proximal tibia was elevated to the medial collateral ligament and medial collateral ligament was left intact throughout the entirety of the case.,At the extramedullary tibial guide, an extended cut was made adjusting for her alignment.  Once this was performed, excess bone was removed.  The reamer was placed along on the femoral canal, after which a 6-degree valgus distal cut was made along the distal femur.  Once this was performed, the distal femoral size in 3 degrees external rotation, 62.5-mm cutting block was placed in 3 degrees external rotation with anterior and posterior cuts as well as anterior and posterior Chamfer cuts remained in the standard fashion.  Excess bone was removed.,Next, the tibia was brought anterior and excised to 71 mm.  It was then punched in standard fashion adjusting for appropriate rotation along the alignment of the tibia.  Once this was performed, a 71-mm tibial trial was placed as well as a 62.5-mm femoral trial was placed with a 12-mm polyethylene insert.,Next, the patella was cut in the standard fashion measuring 31 mm and a patella bed was placed.  The knee was taken for range of motion; had excellent flexion and extension as well as adequate varus and valgus stability.  There was no loosening appreciated.  There is no laxity appreciated along the posterior cruciate ligament.,Once this was performed, the trial components were removed.  The knee was irrigated with fluid and antibiotics, after which the cement was put on the back table, this being Cobalt G, it was placed on the tibia.  The tibial components were tagged in position and placed on the femur.  The femoral components were tagged into position.  All excess cement was removed ___ placement of patella.  It was tagged in position.  A 12-mm polyethylene insert was placed; knee was held in extension and all excess cement was removed.  The cement hardened with the knee in full extension, after which any extra cement was removed.,The wounds were copiously irrigated with saline and antibiotics, and medial parapatellar arthrotomy was closed with #2 Vicryl.  Subcutaneous tissue was approximated with #2-0 Vicryl and the skin was closed with staples.  The patient was awakened from general anesthetic, transferred to the gurney, and taken into postanesthesia care unit in stable condition.  The patient tolerated the procedure well.
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DESCRIPTION: Right total knee arthroplasty using a Biomet cemented components, 62.5-mm right cruciate-retaining femoral component, 71-mm Maxim tibial component, and 12-mm polyethylene insert with 31-mm patella.  All components were cemented with Cobalt G.

orthopedic, degenerative joint disease, knee, total knee arthroplasty, biomet, cemented, cobalt g, arthoplasty, osteoarthritis, polyethylene, cruciate, ligament, patella, femoral, tibial,

Total knee arthroplasty is a major orthopedic surgical procedure, often performed when conservative treatments have failed to relieve joint pain and improve function in a patient with severe degenerative joint disease. The stakes are significant as the surgery involves anesthesia, potential blood loss, and risks such as infection, nerve damage, or the need for revision surgery. Because it significantly impacts the patient's mobility and quality of life, the stakes of this procedure are high. However, the details provided indicate that the surgery was performed successfully with minimal complications, suggesting a positive outcome despite these risks.


Medical Specialty: Neurology
Sample Name: Consult - Alzheimer disease

The patient states that she has been doing fairly well at home.  She balances her own checkbook.  She does not do her own taxes, but she has never done so in the past.  She states that she has no problems with cooking meals, getting her own meals, and she is still currently driving.  She denies burning any dishes because she forgot them on the stove or forgetting what she is doing in the middle of a task or getting lost while she is driving around or getting lost in her own home.  She states that she is very good remembering the names of her family members and does not forget important birthdays such as the date of birth of her grandchildren.  She is unfortunately living alone, and although she seems to miss her grandchildren and is estranged from her son, she denies any symptoms of frank depression.  There is unfortunately no one available to us to corroborate how well she is doing at home.  She lives alone and takes care of herself and does not communicate very much with her brother and sister.  She also does not communicate very much with her son who lives in Santa Cruz or her grandchildren.  She denied any sort of personality change, paranoid ideas or hallucinations.  She does appear to have headaches that can be severe about four times a month and have primarily photophobia and some nausea and occasionally emesis associated with it.  When these headaches are very severe, she goes to the emergency room to get a single shot.  She is unclear if this is some sort of a migraine medication or just a primary pain medication.  She takes Fiorinal for these headaches and she states that this helps greatly.  She denies visual or migraine symptoms.,REVIEW OF SYSTEMS: , Negative for any sort of focal neurologic deficits such as weakness, numbness, visual changes, dysarthria, diplopia or dysphagia.  She also denies any sort of movement disorders, tremors, rigidities or clonus.  Her personal opinion is that some of her memory problems may be due to simply to her age and/or nervousness.  She is unclear as if her memory is any worse than anyone else in her age group.,PAST MEDICAL HISTORY: , Significant for mesothelioma, which was diagnosed seemingly more than 20 to 25 years ago.  The patient was not sure of exactly when it was diagnosed.  This has been treated surgically by debulking operations for which she states that she has undergone about 10 operations.  The mesothelioma is in her abdomen.  She does not know of any history of having lung mesothelioma.  She states that she has never gotten chemotherapy or radiation for her mesothelioma.  Furthermore, she states that her last surgical debulking was more than 10 years ago and her disease has been fairly stable.  She does have a history of three car accidents that she says were all rear-enders where she was hit while essentially in a stopped position.  These have all occurred over the past five years.  She also has a diagnosis of dementing illness, possibly Alzheimer disease from her previous neurology consultation.  This diagnosis was given in March 2006.,MEDICATIONS:,  Fiorinal, p.r.n. aspirin, unclear if baby or full sized, Premarin unclear of the dose.,ALLERGIES:, NONE.,SOCIAL HISTORY:,  Significant for her being without a companion at this point.  She was born in Munich, Germany.  She immigrated to of America in 1957 after her family had to move to Eastern Germany, which was under Russian occupation at that time.  She is divorced.  She used to work as a secretary and later worked as a clerical worker at IBM.  She stopped working more than 20 years ago due to complications from her mesothelioma.  She denies any significant tobacco, alcohol or illicit drugs.  She is bilingual speaking, German and English.  She has known English from before her teens.  She has the equivalent of a high school education in Germany.  She has one brother and one sister, both of whom are healthy and she does not spend much time communicating with them.  She has one son who lives in Santa Cruz.  He has grandchildren.  She is trying to contact with her grandchildren.,FAMILY HISTORY: , Significant for lung, liver, and prostate cancer.  Her mother died in her 80s of "old age," but it appears that she may have had a mild dementing illness at that time.  Whatever that dementing illness was, appears to have started mostly in her 80s per the patient.  No one else appears to have Alzheimer disease including her brother and sister.,PHYSICAL EXAMINATION: , Her blood pressure is 152/92, pulse 80, and weight 80.7 kg.  She is alert and well nourished in no apparent distress.  She occasionally fumbles with questions of orientation, missing the day and the date.  She also did not know the name of the hospital, she thought it was O'Connor and she thought she was in Orange County and also did not know the floor of the hospital that we are in.  She lost three points for recall.  Even with prompting, she could not remember the objects that she was given to remember.  Her Mini Mental Score was 22/30.  There were no naming problems or problems with repetition.  There were also no signs of dysarthria.  Her pupils were bilaterally reactive to light and accommodation.  Her extraocular movements were intact.  Her visual fields were full to confrontation.  Her sensations of her face, arm, and leg were normal.  There were no signs of neglect with double simultaneous stimulation.  Tongue was midline.  Her palate was symmetric.  Her face was symmetric as well.  Strength was approximately 5/5.  She did have some right knee pain and she had a mildly antalgic gait due to her right knee pain.  Her reflexes were symmetric and +2 except for her toes, which were +1 to trace.  Her plantar reflexes were mute.  Her sensation was normal for pain, temperature, and vibration.  There were no signs of ataxia on finger-to-nose and there was no dysdiadochokinesia.  Gait was narrow and she could toe walk briefly and heel walk without difficulty.,SUMMARY:,  Ms. A is a pleasant 72-year-old right-handed woman with a history of mesothelioma that appears stable at this time and likely mild dementia, most likely Alzheimer type.  We tactfully discussed the patient's diagnosis with her, and she felt reassured.  We told her that this most likely was in the earlier stages of disease and she would benefit from trying Aricept.  She stated that she did not have the prescription anymore from her outpatient neurology consult for the Aricept, so we wrote her another prescription for Aricept.  The patient herself seemed very concerned about the stigma of the disease, but our lengthy discussion, expressed genuine understanding as to why her outpatient physician had reported her to DMV.  It was explicitly told to not drive by her outpatient neurologist and we concur with this assessment.  She will follow up with us in the next six months and will call us if she has any problems with the Aricept.  She was written for Aricept to start at 5 mg for three weeks, and if she has no side effects which typically are GI side effects, then she can go up to 10 mg a day.  We also reviewed with Ms. A the findings for outpatient MRI, which showed some mild atrophy per report and also that her metabolic workup, which included an RPR, TSH, and B12 were all within normal limits.,
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DESCRIPTION: Patient with a history of mesothelioma and likely mild dementia, most likely Alzheimer type.

neurology, neurology consultation, dementing illness, alzheimer disease, dementia, alzheimer, mesothelioma,

The situation involves a patient with a diagnosis of mild Alzheimer's disease and a history of mesothelioma. The stakes are moderately high because Alzheimer's disease can progress, impacting the patient's ability to live independently. Additionally, there are safety concerns regarding the patient's driving despite being advised not to. However, the current state of her health appears stable, and there's no immediate life-threatening condition. The stakes are not extremely high but require careful monitoring and management to prevent future risks.


Medical Specialty: Surgery
Sample Name: Laminectomy & Discectomy & Facetectomy

TITLE OF OPERATION: , Revision laminectomy L5-S1, discectomy L5-S1, right medial facetectomy, preparation of disk space and arthrodesis with interbody graft with BMP.,INDICATIONS FOR SURGERY:  ,Please refer to medical record, but in short, the patient is a 43-year-old male known to me, status post previous lumbar surgery for herniated disk with severe recurrence of axial back pain, failed conservative therapy.  Risks and benefits of surgery were explained in detail including risk of bleeding, infection, stroke, heart attack, paralysis, need for further surgery, hardware failure, persistent symptoms, and death.  This list was inclusive, but not exclusive.  An informed consent was obtained after all patient's questions were answered.,PREOPERATIVE DIAGNOSIS:  ,Severe lumbar spondylosis L5-S1, collapsed disk space, hypermobility, and herniated disk posteriorly.,POSTOPERATIVE DIAGNOSIS: , Severe lumbar spondylosis L5-S1, collapsed disk space, hypermobility, and herniated disk posteriorly.,ANESTHESIA: , General anesthesia and endotracheal tube intubation.,DISPOSITION: , The patient to PACU with stable vital signs.,PROCEDURE IN DETAIL:  ,The patient was taken to the operating room.  After adequate general anesthesia with endotracheal tube intubation was obtained, the patient was placed prone on the Jackson table.  Lumbar spine was shaved, prepped, and draped in the usual sterile fashion.  An incision was carried out from L4 to S1.  Hemostasis was obtained with bipolar and Bovie cauterization.  A Weitlaner was placed in the wound and a subperiosteal dissection was carried out identifying the lamina of L4, L5, and sacrum.  At this time, laminectomy was carried out of L5-S1.  Thecal sac was retracted rightward and the foramen was opened and unilateral medial facetectomy was carried out in the disk space.  At this time, the disk was entered with a #15 blade and bipolar.  The disk was entered with straight up and down-biting pituitaries, curettes, and the high speed drill and we were able to takedown calcified herniated disk.  We were able to reestablish the disk space, it was very difficult, required meticulous dissection and then drilling with a diamond bur in the disk space underneath the spinal canal, very carefully holding the spinal canal out of harm's way as well as the exiting nerve root.  Once this was done, we used rasps to remove more disk material anteriorly and under the midline to the left side and then we put in interbody graft of BMP 8 mm graft from Medtronic.  At this time, Dr. X will dictate the posterolateral fusion, pedicle screw fixation to L4 to S1 with compression and will dictate the closure of the wound.  There were no complications.
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DESCRIPTION: Revision laminectomy L5-S1, discectomy L5-S1, right medial facetectomy, preparation of disk space and arthrodesis with interbody graft with BMP.  Status post previous lumbar surgery for herniated disk with severe recurrence of axial back pain, failed conservative therapy.

surgery, revision laminectomy, discectomy, facetectomy, arthrodesis, lumbar spondylosis, hypermobility, collapsed disk space, medial facetectomy, interbody graft, herniated disk, interbody, laminectomy, disk, therapy, lumbar, herniated, space,

The described surgery involves multiple procedures on the lumbar spine: revision laminectomy, discectomy, and facetectomy, along with arthrodesis involving an interbody graft. This is a complex spinal surgery involving significant risks, such as paralysis, bleeding, infection, and even death. Additionally, the patient has a history of a previous lumbar surgery, which can complicate the current procedure. Given these factors, the situation is high-stakes, given the potential for serious complications and the essential nature of the spine. The need for informed consent and the detailed explanation of risks underline the procedure's seriousness.


Medical Specialty: Consult - History and Phy.
Sample Name: Pneumothorax & Subcutaneous Emphysema

REASON FOR CONSULTATION:,  Pneumothorax and subcutaneous emphysema.,HISTORY OF PRESENT ILLNESS: , The patient is a 48-year-old male who was initially seen in the emergency room on Monday with complaints of scapular pain.  The patient presented the following day with subcutaneous emphysema and continued complaints of pain as well as change in his voice.  The patient was evaluated with a CT scan of the chest and neck which demonstrated significant subcutaneous emphysema, a small right-sided pneumothorax, but no other findings.  The patient was admitted for observation.,PAST SURGICAL HISTORY: , Hernia repair and tonsillectomy.,ALLERGIES: , Penicillin.,MEDICATIONS: , Please see chart.,REVIEW OF SYSTEMS:,  Not contributory.,PHYSICAL EXAMINATION:,GENERAL:  Well developed, well nourished, lying on hospital bed in minimal distress.,HEENT:  Normocephalic and atraumatic.  Pupils are equal, round, and reactive to light.  Extraocular muscles are intact.,NECK:  Supple.  Trachea is midline.,CHEST:  Clear to auscultation bilaterally.,CARDIOVASCULAR:  Regular rate and rhythm.,ABDOMEN:  Soft, nontender, and nondistended.  Normoactive bowel sounds.,EXTREMITIES:  No clubbing, edema, or cyanosis.,SKIN:  The patient has significant subcutaneous emphysema of the upper chest and anterior neck area although he states that the subcutaneous emphysema has improved significantly since yesterday.,DIAGNOSTIC STUDIES:,  As above.,IMPRESSION: , The patient is a 48-year-old male with subcutaneous emphysema and a small right-sided pneumothorax secondary to trauma.  These are likely a result of either a parenchymal lung tear versus a small tracheobronchial tree rend.,RECOMMENDATIONS:,  At this time, the CT Surgery service has been consulted and has left recommendations.  The patient also is awaiting bronchoscopy per the Pulmonary Service.  At this time, there are no General Surgery issues.
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DESCRIPTION: Consult for subcutaneous emphysema and a small right-sided pneumothorax secondary to trauma.

consult - history and phy., trauma, tracheobronchial, bronchoscopy, scapular pain, subcutaneous emphysema, pneumothorax, subcutaneous, emphysema,

The situation involves a patient with subcutaneous emphysema and a pneumothorax, which are medical conditions that can potentially lead to serious complications if not properly monitored and treated. Pneumothorax, in particular, can compromise respiratory function, and the involvement of trauma suggests possible underlying injuries. The need for specialist consultation and potential procedures such as bronchoscopy underscores the importance of careful management. Therefore, the stakes are relatively high given the medical implications and the need for multidisciplinary assessment and intervention.