Medical Specialty: Consult - History and Phy.
Sample Name: Dietary Consult - 3

SUBJECTIVE:,  The patient is brought in by an assistant with some of his food diary sheets.  They wonder if the patient needs to lose anymore weight.,OBJECTIVE:,  The patient's weight today is 186-1/2 pounds, which is down 1-1/2 pounds in the past month.  He has lost a total of 34-1/2 pounds.  I praised this.  I went over his food diary and praised all of his positive food choices reported, especially his use of sugar-free Kool-Aid, sugar-free pudding, and diet pop.  I encouraged him to continue all of that, as well as his regular physical activity.,ASSESSMENT:,  The patient is losing weight at an acceptable rate.  He needs to continue keeping a food diary and his regular physical activity.,PLAN:,  The patient plans to see Dr. XYZ at the end of May 2005.  I recommended that they ask Dr. XYZ what weight he would like for the patient to be at.  Follow up will be with me June 13, 2005.
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DESCRIPTION: The patient is brought in by an assistant with some of his food diary sheets.

consult - history and phy., weight, kool-aid, food diary sheets, diary sheets, physical activity, food diary, dietary, sheets, diary, food

The situation involves a routine dietary consultation with a focus on weight management. The patient is showing progress in weight loss, has good dietary habits, and is physically active. Additionally, there are planned follow-ups with healthcare providers. The stakes are low as there are no immediate health threats or significant health decisions being made at this moment.


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

Medical Specialty: Chiropractic
Sample Name: Chiropractic IME - 1

P.O. Box 12345,City, State ,RE: EXAMINEE : Abc,CLAIM NUMBER : 12345-67890,DATE OF INJURY : April 20, 2003,DATE OF EXAMINATION : August 26, 2003,EXAMINING PHYSICIANS : Y Z, DC,Prior to the beginning of the examination, it is explained to the examinee that this examination is intended for evaluative purposes only, and that it is not intended to constitute a general medical examination. It is explained to the examinee that the traditional doctor-patient relationship does not apply to this examination, and that a written report will be provided to the agency requesting this examination. It has also been emphasized to the examinee that he should not attempt any physical activity beyond his tolerance, in order to avoid injury.,CHIEF COMPLAINTS: , Improved focal lower back pain.,HISTORY: , Abc is a 26-year-old man who immigrated to this country approximately six years ago. He speaks "un poquito" English and an interpreter is provided. He has worked for the last four years at Floragon Forest Products, where he normally functions as a "stacker." He indicates that another worker was on vacation, and because of this he was put on another job in which he separated logs using a picaroon. He was doing this on April 20, 2003, and was pulling on the picaroon when it gave way, and he fell backwards landing on a metal step, which was approximately 1 foot off of the ground. He demonstrates that he came down square on the step and did not fall backwards or hyperextend over it. He did not hit his upper back or neck or shoulders, and only sat down on the step as described. He had "a little" pain in his back at that time, but was able to get up and continue working. He completed his shift that day and returned to work the following day. He had the next two days off. He says that his symptoms persisted and increased, and on April 25, 2003, he went to the First Choice Physicians Chiropractic and Rehab Clinic, where he came under the care of Dr. Abcd, DC. The file contains an entrance form completed by Mr. Abc which indicates at the bottom under "previous occurrence of the same pain" a notation of "Yes, but it was not really the same, it was just a little and tolerable." There is an additional note on the side which states "no pain prior to this injury or on that day, occasional (but low back)." Saw this notation, he says today that he did not state this and that the form was done by "Edna" at Dr. Abcd's office.,Mr. Abc was initially treated three times a week and states that this has now been reduced to twice per week. He does not know how long the chiropractic treatment is to continue. Initially, he has been seen by Dr. Xyz on three occasions, the last being on August 15, 2003. Dr. Xyz has basically referred him back to Dr. Abcd for continued chiropractic management.,Mr. Abc has now returned to his normal job as a stacker and is able to do that with no significant increased pain. He does mention, however, that bending over, picking up anything particularly heavy is bothersome; however, he does not normally have to do that. He denies any new accident or injury that would be contributory either as a result of his work or outside activities or any motor vehicle accident. He does not participate physically in any sports or hobbies that would be a factor.,PRESENT COMPLAINTS: , Mr. Abc indicates at this time that he is overall better in that initially he had difficulty "moving." He grades his current overall level of pain as a 2 to 4 on a scale from 0 to 10, stating that the worst he had was at 6-7. He now has "good and bad days" which depends on his activity level noting that he is better over the weekend. He localizes his pain to the midline lumbosacral region. He states that initially he did experience some diffuse radiation into both lower extremities, but that this has now resolved. He occasionally will notice some tightness behind both knees, but again no radicular type of distribution. He denies any focal muscular weakness or sphincter disturbance. His quality of the pain at this time is a "tightness" which bothers him, again, primarily with bending at the waist and lifting. He is able to do his normal activities of life, including his work without any significant problem, noting again only increased pain with bending and lifting.,PAST HISTORY: , Mr. Abc denies any prior similar complaints or treatments. He denies any previous specific lower back injury. He has enjoyed essentially good lifetime health and denies any concurrent medical conditions or problems. He has seasonal allergies only with no known drug hypersensitivities. He has not been hospitalized overnight and has had no surgeries in his life. He currently takes OTC Advil and Tylenol for lower back pain, but no prescriptive medication. He does not smoke, drink, or use street drugs of any type. Review of systems and family history are generally noncontributory.,SOCIO-ECONOMIC HISTORY: , Mr. Abc, as indicated, was born and reared in Mexico and immigrated into this country six years ago.,Education: He has our equivalent of a high school education in Mexico with no additional formal education in United States.,Military History: He has no military experience in his life.,Work History: He currently is doing his normal work activities as a stacker without arbitrary restrictions or limitations. He is not receiving any Workers Compensation or other benefits at this time.,PHYSICAL EXAMINATION: , Abc presents as a cooperative and straightforward 26-year-old Hispanic male. He has a very thin body habitus with a reported height of 5 feet 7 inches and weight of 125 pounds. He is right hand dominant. He is noted to sit comfortably throughout the history taking process conversant with the interpreter and myself without observable guarding or postural conversation or motion. He did stand readily to full upright with equal weightbearing and exhibits normal spinal posture with double hips and shoulders. Lumbar lordosis is normal. He ambulates without a limp or lift, and is able to walk on heels and toes and perform a full squat and rise and hop without difficulty with some expression of increased lower back pain. Waddell's testing is negative on compression and traction with some slight increased lower back pain on passive rotation.,Kemp's maneuver of posterolateral bending has some increased localized lumbosacral pain, but no radiation distally into the buttocks or lower extremities.,Active lumbar ranges of motion with double inclinometer are:,Flexion 70 degrees.,Extension 20 degrees.,Side bending symmetric at 28 degrees.,He complains of lower back pain at the extremes of flexion only. Motion palpation reveals full mobility without any detectable intrasegmental fixation with normal symmetry and alignment.,Tendon reflexes are 2+ and symmetric at the knees and ankles without sensory loss to pinprick. Babinski's are neutral, and there is no clonus.,Manual muscle testing reveals 5/5 strength at the hips, knees, and ankles without give-way or complaint.,Supine passive straight leg raising is limited by hamstring tightness to 66 degrees bilaterally, but causes no expression of lower back pain or radiation. Cross leg with rotation hip joint motion is full on either side without reported hip or back pain. Hip flexion is symmetric at 130 degrees, again without complaint. Leg lengths appeared visually symmetric. Mid calf girth is 11-1/2 inches bilaterally. Five inches above the knees measured 13 inches right and left. The seated SLR is done to 90 degrees, and he brings his fingertips 2 inches from his toes, showing good flexibility at the waist despite the hamstring tightness noted in the supine straight leg raising test.,In the prone position, he has good gluteal strength on either side with Yeoman's test causing some increased lumbosacral pain but no focal sacroiliac involvement. No sacroiliac fixation is identified. Hibbs test is negative on either side.,On palpation, he reports midline tenderness at L5-S1 without additional areas of tenderness noted even to very firm palpatory pressure in the entirety of the lumbar spine over the pelvis. He indicates no focal or sacroiliac, sciatic notch, or trochanteric tenderness on either side. No definitive muscular spasm is noted in the lumbar paraspinal musculature.,Mr. Abc tolerated the examination process without apparent or expressed ill effect. ,IMAGING STUDIES:,  AP and lateral lumbar/pelvic views dated May 15, 2003 are reviewed. The films are negative for recent fracture or pathology. There appears to be a transitional lumbosacral area with a spatulated transverse process of L1 and slight narrowing of the lumbosacral disc space. No additional abnormalities are identified. The hip and sacroiliac articulations appear well preserved. Disc spacing in the rest of the lumbar spine appears normal, and no significant degenerative changes are identified. Soft tissue appeared normal without paraspinal mass or abnormality.,DIAGNOSIS: , Lumbosacral contusion/strain relative to the April 20, 2003 industrial accident - objectively resolved.,SUMMARY: , Discussion and recommendations in response to questions posed in your August 15, 2003 letter:,1. What is your diagnosis of the worker's condition as a result of the injury? Please provide objective medical findings that support your diagnosis. Please indicate if the objective findings are reproducible, measurable, or observable, and how.,The diagnosis of the workers condition secondary to the described April 20, 2003 fall is by history a lumbosacral contusion/strain. This impression is primarily made based on his history noting that at this time, he has no abnormal objective findings.,2. In your opinion, is the work injury a contributing cause of the diagnosis? If so, is the work injury the material contributing cause of the diagnosis? Please provide an explanation for your opinion.,It would appear that the work injury was the major contributing cause of the diagnosis.,3. Are there any off work factors that may have caused or contributed to the worker's current complaints or condition? (Such as idiopathic causes, predisposition, congenital abnormalities, off work injuries, etc.).
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DESCRIPTION: Chiropractic IME with answers to questions from Insurance Company.

The context provided pertains to a chiropractic Independent Medical Examination (IME) for evaluative purposes regarding a workplace injury claim. While this documentation involves assessment and insurance matters, it does not directly involve immediate life-threatening medical conditions or critical healthcare decisions affecting the examinee's immediate health. The high-stakes nature would be more relevant in terms of the potential financial and employment implications for the worker or company rather than immediate medical risk. Thus, while it does have significance, especially for insurance and employment, it's not extremely high-stakes in a life-or-death manner.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Office Notes
Sample Name: Nephrology Office Visit - 1

HISTORY OF PRESENT ILLNESS:  ,The patient is a 78-year-old woman here because of recently discovered microscopic hematuria.  History of present illness occurs in the setting of a recent check up, which demonstrated red cells and red cell casts on a routine evaluation.  The patient has no new joint pains; however, she does have a history of chronic degenerative joint disease.  She does not use nonsteroidal agents.  She has had no gross hematuria and she has had no hemoptysis.,REVIEW OF SYSTEMS: , No chest pain or shortness of breath, no problem with revision.  The patient has had decreased hearing for many years.  She has no abdominal pain or nausea or vomiting.  She has no anemia.  She has noticed no swelling.  She has no history of seizures.,PAST MEDICAL HISTORY: , Significant for hypertension and hyperlipidemia.  There is no history of heart attack or stroke.  She has had bilateral simple mastectomies done 35 years ago.  She has also had one-third of her lung removed for carcinoma (probably an adeno CA related to a pneumonia.)  She also had hysterectomy in the past.,SOCIAL HISTORY: , She is a widow.  She does not smoke.,MEDICATIONS:,1.  Dyazide one a day.,2.  Pravachol 80 mg a day in the evening.,3.  Vitamin E once a day.,4.  One baby aspirin per day.,FAMILY HISTORY:,  Unremarkable.,PHYSICAL EXAMINATION:,  She looks younger than her stated age of 78 years.  She was hard of hearing, but could read my lips.  Respirations were 16.  She was afebrile.  Pulse was about 90 and regular.  Her gait was normal.  Blood pressure is 140/70 in her left arm seated.  HEENT:  She had arcus cornealis.  The pupils were equal.  The sclerae were not icteric.  The conjunctivae were pink.  NECK:  The thyroid is not palpated.  No nodes were palpated in the neck.  CHEST:  Clear to auscultation.  She had no sacral edema.  CARDIAC:  Regular, but she was tachycardic at the rate of about 90.  She had no diastolic murmur.  ABDOMEN:  Soft, and nontender.  I did not palpate the liver.  EXTREMITIES:  She had no appreciable edema.  She had no digital clubbing.  She had no cyanosis.  She had changes of the degenerative joint disease in her fingers.  She had good pedal pulses.  She had no twitching or myoclonic jerks.,LABORATORY DATA: , The urine, I saw 1-2 red cells per high power fields.  She had no protein.  She did have many squamous cells.  The patient has creatinine of 1 mg percent and no proteinuria.  It seems unlikely that she has glomerular disease; however, we cannot explain the red cells in the urine.,PLAN: , To obtain a routine sonogram.  I would also repeat a routine urinalysis to check for blood again.  I have ordered a C3 and C4 and if the repeat urine shows red cells, I will recommend a cystoscopy with a retrograde pyelogram.
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DESCRIPTION: Nephrology office visit for followup of microscopic hematuria.

office notes, nephrology, creatinine, cystoscopy, glomerular, high power fields, hyperlipidemia, hypertension, microscopic hematuria, proteinuria, pyelogram, red cell, retrograde, sonogram, urinalysis, red cells, hematuria

The situation involves a medical follow-up for a 78-year-old patient with recently discovered microscopic hematuria. While this could indicate potential renal or urological issues, such as an underlying glomerular disease or malignancy, the current plan is for further diagnostic evaluations, including a sonogram and repeat urinalysis, which suggests the condition is being monitored but not immediately life-threatening. Given the patient's age and history, certain risks are involved, but the stakes are not immediate or critical as there is no evidence of acute distress or severe symptoms.


Medical Specialty: Speech - Language
Sample Name: Barium Swallow Study & Speech Evaluation - 1

SUBJECTIVE: , The patient is a 60-year-old female, who complained of coughing during meals.  Her outpatient evaluation revealed a mild-to-moderate cognitive linguistic deficit, which was completed approximately 2 months ago.  The patient had a history of hypertension and TIA/stroke.  The patient denied history of heartburn and/or gastroesophageal reflux disorder.  A modified barium swallow study was ordered to objectively evaluate the patient's swallowing function and safety and to rule out aspiration.,OBJECTIVE: , Modified barium swallow study was performed in the Radiology Suite in cooperation with Dr. ABC.  The patient was seated upright in a video imaging chair throughout this assessment.  To evaluate the patient's swallowing function and safety, she was administered graduated amounts of liquid and food mixed with barium in the form of thin liquid (teaspoon x2, cup sip x2); nectar-thick liquid (teaspoon x2, cup sip x2); puree consistency (teaspoon x2); and solid food consistency (1/4 cracker x1).,ASSESSMENT,ORAL STAGE:,  Premature spillage to the level of the valleculae and pyriform sinuses with thin liquid.  Decreased tongue base retraction, which contributed to vallecular pooling after the swallow.,PHARYNGEAL STAGE: , No aspiration was observed during this evaluation.  Penetration was noted with cup sips of thin liquid only.  Trace residual on the valleculae and on tongue base with nectar-thick puree and solid consistencies.  The patient's hyolaryngeal elevation and anterior movement are within functional limits.  Epiglottic inversion is within functional limits.,CERVICAL ESOPHAGEAL STAGE:  ,The patient's upper esophageal sphincter opening is well coordinated with swallow and readily accepted the bolus.  Radiologist noted reduced peristaltic action of the constricted muscles in the esophagus, which may be contributing to the patient's complaint of globus sensation.,DIAGNOSTIC IMPRESSION:,  No aspiration was noted during this evaluation.  Penetration with cup sips of thin liquid.  The patient did cough during this evaluation, but that was noted related to aspiration or penetration.,PROGNOSTIC IMPRESSION: ,Based on this evaluation, the prognosis for swallowing and safety is good.,PLAN: , Based on this evaluation and following recommendations are being made:,1.  The patient to take small bite and small sips to help decrease the risk of aspiration and penetration.,2.  The patient should remain upright at a 90-degree angle for at least 45 minutes after meals to decrease the risk of aspiration and penetration as well as to reduce her globus sensation.,3.  The patient should be referred to a gastroenterologist for further evaluation of her esophageal function.,The patient does not need any skilled speech therapy for her swallowing abilities at this time, and she is discharged from my services.
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DESCRIPTION:

speech - language, gastroesophageal reflux disorder, cognitive linguistic deficit, tia, stroke, swallowing function, swallow study, barium swallow study, globus sensation, esophageal, penetration

The situation involves a swallowing evaluation for a patient with a history of stroke and cognitive deficits, exploring the risk of aspiration. The findings indicated a risk of penetration with thin liquids, and recommendations were made to minimize this risk. There's no immediate life-threatening situation involving the patient, such as severe aspiration or choking risk, as the evaluation concluded with a good prognosis. Hence, the stakes are more about ensuring ongoing safety in daily living for the patient, with follow-up recommendations made to improve swallowing safety and comfort.


Medical Specialty: Surgery
Sample Name: LEEP

DIAGNOSIS:,1.  Broad-based endocervical poly.,2.  Broad- based pigmented, raised nevus, right thigh.,OPERATION:,1.  LEEP procedure of endocervical polyp.,2.  Electrical excision of pigmented mole of inner right thigh.,FINDINGS: , There was a 1.5 x 1.5 cm broad-based pigmented nevus on the inner thigh that was excised with a wire loop.  Also, there was a butt-based, 1-cm long endocervical polyp off the posterior lip of the cervix slightly up in the canal.,PROCEDURE: , With the patient in the supine position, general anesthesia was administered.  The patient was put in the dorsal lithotomy position and prepped and draped for dilatation and curettage in a routine fashion.,An insulated posterior weighted retractor was put in.  Using the LEEP tenaculum, we were able to grasp the anterior lip of the cervix with a large wire loop at 35 cutting, 30 coagulation.  The endocervical polyp on the posterior lip of the cervix was excised.,Then changing from a 50 of coagulation and 5 cutting, the base of the polyp was electrocoagulated, which controlled all the bleeding.  The wire loop was attached, and the pigmented raised nevus on the inner thigh was excised with the wire loop.  Cautery of the base was done, and then it was closed with figure-of-eight 3-0 Vicryl sutures.  A band-aid was applied over this.,Rechecking the cervix, no bleeding was noted.  The patient was laid flat on the table, awakened, and moved to the recovery room bed and sent to the recovery room in satisfactory condition.
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DESCRIPTION: LEEP procedure of endocervical polyp and Electrical excision of pigmented mole of inner right thigh.

surgery, endocervical polyp, pigmented mole, polyp, leep tenaculum, leep, cervix, endocervical, pigmented

The situation involves two surgical procedures: a LEEP procedure for an endocervical polyp and an electrical excision of a pigmented mole on the thigh. Both procedures, while generally routine, involve surgical intervention, anesthesia, and potential for complications such as bleeding or infection. The diagnosis of a pigmented nevus could also be significant if there is suspicion of malignancy, requiring histopathological examination. Although LEEP procedures are common, the involvement of anesthesia and excision of a potentially suspicious mole raises the stakes slightly.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Lobectomy - VATS

PREOPERATIVE DIAGNOSIS:,  Right middle lobe lung cancer.,POSTOPERATIVE DIAGNOSIS: , Right middle lobe lung cancer.,PROCEDURES PERFORMED:,1.  VATS right middle lobectomy.,2.  Fiberoptic bronchoscopy thus before and after the procedure.,3.  Mediastinal lymph node sampling including levels 4R and 7.,4.  Tube thoracostomy x2 including a 19-French Blake and a 32-French chest tube.,5.  Multiple chest wall biopsies and excision of margin on anterior chest wall adjacent to adherent tumor.,ANESTHESIA:  ,General endotracheal anesthesia with double-lumen endotracheal tube.,DISPOSITION OF SPECIMENS: , To pathology both for frozen and permanent analysis.,FINDINGS:,  The right middle lobe tumor was adherent to the anterior chest wall.  The adhesion was taken down, and the entire pleural surface along the edge of the adhesion was sent for pathologic analysis.  The final frozen pathology on this entire area returned as negative for tumor.  Additional chest wall abnormalities were biopsied and sent for pathologic analysis, and these all returned separately as negative for tumor and only fibrotic tissue.  Several other biopsies were taken and sent for permanent analysis of the chest wall.  All of the biopsy sites were additionally marked with Hemoclips.  The right middle lobe lesion was accompanied with distal pneumonitis and otherwise no direct involvement of the right upper lobe or right lower lobe.,ESTIMATED BLOOD LOSS: , Less than 100 mL.,CONDITION OF THE PATIENT AFTER SURGERY: , Stable.,HISTORY OF PROCEDURE:,  This patient is well known to our service.  He was admitted the night before surgery and given hemodialysis and had close blood sugar monitoring in control.  The patient was subsequently taken to the operating room on April 4, 2007, was given general anesthesia and was endotracheally intubated without incident.  Although, he had markedly difficult airway, the patient had fiberoptic bronchoscopy performed all the way down to the level of the subsegmental bronchi.  No abnormalities were noted in the entire tracheobronchial tree, and based on this, the decision was made to proceed with the surgery.  The patient was kept in the supine position, and the single-lumen endotracheal tube was removed and a double-lumen tube was placed.  Following this, the patient was placed into the left lateral decubitus position with the right side up and all pressure points were padded.  Sterile DuraPrep preparation on the right chest was placed.  A sterile drape around that was also placed.  The table was flexed to open up the intercostal spaces.  A second bronchoscopy was performed to confirm placement of the double-lumen endotracheal tube.  Marcaine was infused into all incision areas prior to making an incision.  The incisions for the VATS right middle lobectomy included a small 1-cm incision for the auscultatory incision approximately 4 cm inferior to the inferior tip of the scapula.  The camera port was in the posterior axillary line in the eighth intercostal space through which a 5-mm 30-degree scope was used.  Third incision was an anterior port, which was approximately 2 cm inferior to the inframammary crease and the midclavicular line in the anterior sixth intercostal space, and the third incision was a utility port, which was a 4 cm long incision, which was approximately one rib space below the superior pulmonary vein.  All of these incisions were eventually created during the procedure.  The initial incision was the camera port through which, under direct visualization, an additional small 5-mm port was created just inferior to the anterior port.  These two ports were used to identify the chest wall lesions, which were initially thought to be metastatic lesions.  Multiple biopsies of the chest wall lesions were taken, and the decision was made to also insert the auscultatory incision port.  Through these three incisions, the initial working of the diagnostic portion of the chest wall lesion was performed.  Multiple biopsies were taken of the entire chest wall offers and specimens came back as negative.  The right middle lobe was noted to be adherent to the anterior chest wall.  This area was taken down and the entire pleural surface along this area was taken down and sent for frozen pathologic analysis.  This also returned as negative with only fibrotic tissue and a few lymphocytes within the fibrotic tissue, but no tumor cells.  Based on this, the decision was made to not proceed with chest wall resection and continue with right middle lobectomy.  Following this, the anterior port was increased in size and the utility port was made and meticulous dissection from an anterior to posterior direction was performed.  The middle lobe branch of the right superior pulmonary vein was initially dissected and stapled with vascular load 45-mm EndoGIA stapler.  Following division of the right superior pulmonary vein, the right middle lobe bronchus was easily identified.  Initially, this was thought to be the main right middle lobe bronchus, but in fact it was the medial branch of the right middle lobe bronchus.  This was encircled and divided with a blue load stapler with a 45-mm EndoGIA.  Following division of this, the pulmonary artery was easily identified.  Two branches of the pulmonary artery were noted to be going into the right middle lobe.  These were individually divided with a vascular load after encircling with a right angle clamp.  The vascular staple load completely divided these arterial branches successfully from the main pulmonary artery trunk, and following this, an additional branch of the bronchus was noted to be going to the right middle lobe.  A fiberoptic bronchoscopy was performed intraoperatively and confirmed that this was in fact the lateral branch of the right middle lobe bronchus.  This was divided with a blue load stapler 45 mm EndoGIA.  Following division of this, the minor and major fissures were completed along the edges of the right middle lobe separating the right upper lobe from the right middle lobe as well as the right middle lobe from the right lower lobe.  Following complete division of the fissure, the lobe was put into an EndoGIA bag and taken out through the utility port.  Following removal of the right middle lobe, a meticulous lymph node dissection sampling was performed excising the lymph node package in the 4R area as well as the 7 lymph node package.  Node station 8 or 9 nodes were easily identified, therefore none were taken.  The patient was allowed to ventilate under water on the right lung with no obvious air leaking noted.  A 19-French Blake was placed into the posterior apical position and a 32-French chest tube was placed in the anteroapical position.  Following this, the patient's lung was allowed to reexpand fully, and the patient was checked for air leaking once again.  Following this, all the ports were closed with 2-0 Vicryl suture used for the deeper tissue, and 3-0 Vicryl suture was used to reapproximate the subcutaneous tissue and 4-0 Monocryl suture was used to close the skin in a running subcuticular fashion.  The patient tolerated the procedure well, was extubated in the operating room and taken to the recovery room in stable condition.
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DESCRIPTION: VATS right middle lobectomy, fiberoptic bronchoscopy, mediastinal lymph node sampling, tube thoracostomy x2, multiple chest wall biopsies and excision of margin on anterior chest wall adjacent to adherent tumor.

cardiovascular / pulmonary, middle lobe, endogia, fiberoptic, mediastinal lymph node, vats, bronchoscopy, chest tube, chest wall, endotracheal tube, endotracheally, lobectomy, lung cancer, pneumonitis, sampling, thoracostomy, utility port, lumen endotracheal tube, superior pulmonary vein, chest wall lesions, anterior chest wall, middle lobectomy, fiberoptic bronchoscopy, anterior chest, lymph node, node, port, chest, bronchus, tumor, pulmonary, incision,

The document describes a complex surgical procedure (Video-Assisted Thoracoscopic Surgery - VATS) for a patient with right middle lobe lung cancer. This involves a right middle lobectomy along with bronchoscopy, lymph node sampling, and multiple biopsies. Such a surgery is critical given the nature of cancer treatment and potential complications related to the patient's condition and airway difficulties. Given that the procedure involved multiple incisions, delicate surgical maneuvers, and thorough pathology to confirm the absence of malignant cells, it indicates high-stakes to ensure successful removal of the cancer while preserving patient stability. Furthermore, the patient’s status post-surgery needs to ensure stability not just immediately after but also in the follow-up care to monitor for complications such as infection or recurrence.


Medical Specialty: Neurosurgery
Sample Name: Pterional Craniotomy

PREOPERATIVE DIAGNOSIS:  ,Status post spontaneous hemorrhage from medial temporal arteriovenous malformation with arteriographic evidence of associated aneurysm.,POSTOPERATIVE DIAGNOSIS: , Status post spontaneous hemorrhage from medial temporal arteriovenous malformation with arteriographic evidence of associated aneurysm.,OPERATION: , Right pterional craniotomy with obliteration of medial temporal arteriovenous malformation and associated aneurysm and evacuation of frontotemporal intracerebral hematoma.,ANESTHESIA: , Endotracheal.,ESTIMATED BLOOD LOSS: , 250 mL,REPLACEMENTS:  ,3 units of packed cells.,DRAINS:,  None.,COMPLICATIONS: , None.,PROCEDURE:  ,With the patient prepped and draped in the routine fashion in the supine position with the head in a Mayfield headrest, turned 45 degrees to the patient's left and a small roll placed under her right shoulder and hip, the previously made pterional incision was reopened and extended along its posterior inferior limb to the patient's zygoma.  Additional aspect of the temporalis muscle and fascia were incised with cutting Bovie current with effort made to preserve the posterior limb of the external carotid artery.  The scalp and temporalis muscle were then retracted anteroinferiorly with 0 silk sutures, attached rubber bands and Allis clamps and similar retraction of the posterior aspect of temporalis was retracted with 0 silk suture, attached with rubber bands and Allis clamps.  The bone flap, which had not been fixed in place was removed.  An additional portion of the temporofrontal bone based at the zygoma was removed with a B1 dissecting tool, B1 attached to the Midas Rex instrumentation.  Further bone removal was accomplished with Leksell rongeur, and hemostasis controlled with the use of bone wax.,At this point, a retractor was placed along the frontal lobe for visualization of the perichiasmatic cistern with visualization made of the optic nerve and carotid artery.  It should be noted that cottonoid paddies were placed over the brain to protect the cortical surface of the brain both underneath the retractor and the remainder of the exposed cortex.  The sylvian fissure was then dissected with the dissection description being dictated by Dr. X.,Following successful splitting of the sylvian fissure to its apparent midplate, attention was next turned to the temporal tip where the approximate location of the cerebral aneurysm noted on CT angio, as well as conventional arteriography was noted and a peel incision was made extending from the temporal tip approximately 3 cm posterior.  This was enlarged with bipolar coagulation and aspiration and inferior dissection accomplished under the operating microscope until the dome of, what appeared to be, an aneurysm could be visualized.,Dissection around the dome with bipolar coagulation and aspiration revealed a number of abnormal vessels, which appeared to be involved with the aneurysm at its base and these were removed with bipolar coagulation.  Until circumferential dissection revealed 1 major arterial supply to the base of the aneurysm, this was felt to be able to be handled with bipolar coagulation, which was done and the vessel then cut with microscissors and the aneurysm removed in toto.,Attention was next turned to the apparent nidus of the arteriovenous malformation, which was somewhat medial and inferior to the aneurysm and the nidus was then dissected with the use of bipolar coagulation and aspiration microscissors as further described by Dr. X. With removal of the arteriovenous malformation, attention was then turned to the previous frontal cortical incision, which was the site of partial decompression of the patient's intracerebral hematoma on the day of her admission.  Self-retaining retractors were placed within this cortical incision, and the hematoma cavity entered with additional hematoma removed with general aspiration and irrigation.  Following removal of additional hematoma, the bed of the hematoma site was lined with Surgicel.  Irrigation revealed no further active bleeding, and it was felt that at this time both the arteriovenous malformation, associated aneurysm, and intracerebral hematoma had been sequentially dealt with.,The cortical surface was then covered with Surgicel and the dura placed over the surface of the brain after coagulation of the dural edges, the freeze dried fascia, which had been used at the time of the 1st surgery was replaced over the surface of the brain with additional areas of cortical exposure covered with a DuraGuard.  The 2nd bone flap from the inferior frontotemporal region centered along the zygoma was reattached to the initial bone flap at 3 sites using a small 2-holed plate and 3-mm screws and the portable minidriver.,With this, return of the inferior plate accomplished, it was possible to reposition the bone flaps into their initial configuration, and attachments were secured anterior and posterior with somewhat longer 2-holed plates and 3-mm screws to the frontal and posterior temporal parietal region.  The wound was then closed.  It should be noted that a pledget of Gelfoam had been placed over the entire dural complex prior to returning the bone flap.  The wound was then closed by approximating the temporalis muscle with 2-0 Vicryl suture, the fascia was closed with 2-0 Vicryl suture, and the galea was closed with 2-0 interrupted suture, and the skin approximated with staples.  The patient appeared to tolerate the procedure well without complications.
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DESCRIPTION: Right pterional craniotomy with obliteration of medial temporal arteriovenous malformation and associated aneurysm and evacuation of frontotemporal intracerebral hematoma.

neurosurgery, hemorrhage, arteriovenous malformation, aneurysm, pterional craniotomy, bone flap, bipolar coagulation, arteriovenous, pterional, malformation, hematoma, intracerebral,

The situation involves a complex neurosurgical procedure known as a pterional craniotomy, which is performed to treat conditions such as an arteriovenous malformation (AVM) and associated aneurysm. These conditions can be life-threatening if not properly treated, and the procedure itself is intricate and high-risk due to the critical location in the brain and potential for complications. Successful surgical intervention is crucial to prevent further hemorrhage or neurological injury. Therefore, it involves significant risk to the patient's life and health.


Medical Specialty: Urology
Sample Name: Adrenalectomy & Umbilical Hernia Repair

PREOPERATIVE DIAGNOSES,1.  Adrenal mass, right sided.,2.  Umbilical hernia.,POSTOPERATIVE DIAGNOSES,1.  Adrenal mass, right sided.,2.  Umbilical hernia.,OPERATION PERFORMED: , Laparoscopic hand-assisted left adrenalectomy and umbilical hernia repair.,ANESTHESIA:  ,General.,CLINICAL NOTE: , This is a 52-year-old inmate with a 5.5 cm diameter nonfunctioning mass in his right adrenal.  Procedure was explained including risks of infection, bleeding, possibility of transfusion, possibility of further treatments being required.  Alternative of fully laparoscopic are open surgery or watching the lesion.,DESCRIPTION OF OPERATION:  ,In the right flank-up position, table was flexed.  He had a Foley catheter in place.  Incision was made from just above the umbilicus, about 5.5 cm in diameter.  The umbilical hernia was taken down.  An 11 mm trocar was placed in the midline, superior to the GelPort and a 5 mm trocar placed in the midaxillary line below the costal margin.  A liver retractor was placed to this.,The colon was reflected medially by incising the white line of Toldt.  The liver attachments to the adrenal kidney were divided and the liver was reflected superiorly.  The vena cava was identified.  The main renal vein was identified.  Coming superior to the main renal vein, staying right on the vena cava, all small vessels were clipped and then divided.  Coming along the superior pole of the kidney, the tumor was dissected free from top of the kidney with clips and Bovie.  The harmonic scalpel was utilized superiorly and laterally.  Posterior attachments were divided between clips and once the whole adrenal was mobilized, the adrenal vein and one large adrenal artery were noted, doubly clipped, and divided.  Specimen was placed in a collection bag, removed intact.,Hemostasis was excellent.,The umbilical hernia had been completely taken down.  The edges were freshened up.  Vicryl #1 was utilized to close the incision and 2-0 Vicryl was used to close the fascia of the trocar.,Skin closed with clips.,He tolerated the procedure well.  All sponge and instrument counts were correct.  Estimated blood loss less than 100 mL.,The patient was awakened, extubated, and returned to recovery room in satisfactory condition.
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DESCRIPTION: Laparoscopic hand-assisted left adrenalectomy and umbilical hernia repair.  Patient with a 5.5-cm diameter nonfunctioning mass in his right adrenal.

urology, adrenalectomy, laparoscopic hand-assisted, umbilical hernia repair, vena cava, renal vein, hernia repair, laparoscopic, umbilical, hernia,

The document describes a surgical procedure involving adrenalectomy and hernia repair. Surgery inherently involves risks such as infection, bleeding, and the need for transfusion, which makes it high-stakes, especially considering the potential complications and the fact it's involving a mass in the adrenal gland, which might implicate other physiological issues. Postoperative recovery also includes considerations that further heighten the stakes. These factors contribute to a moderately high-stakes situation, requiring precision and caution.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Hand Discomfort - Followup

REASON FOR RETURN VISIT: , Followup of left hand discomfort and systemic lupus erythematosus.,HISTORY OF PRESENT ILLNESS: , The patient is a 56-year-old female with a history of systemic lupus erythematosus, who was last seen in rheumatology clinic approximately 4 months ago for bilateral hand discomfort, left greater than right.  The patient was seen on 10/30/07.  She had the same complaint.  She was given a trial of Elavil at bedtime because the thought was to see that represented ulnar or radial neuropathy.  She was also given a prescription for Zostrix cream but was unable to get it filled because of insurance coverage.  The patient reports some worsening of the symptoms especially involving at the dorsum of the left hand, and she points to the area that actually involves the dorsal aspect of the second, third, and fourth digits.  The patient recently has developed what sounds like an upper respiratory problem with a nonproductive cough for 3 days, although she reports that she has had subjective fevers for the past 3 or 4 days, but has not actually taken the temperature.  She has not had any night sweats or chills.  She has had no recent problems with chest pain, chest discomfort, shortness of breath or problems with GU or GI complaints.  She is returning today for routine followup evaluation.,CURRENT MEDICATIONS:,1.  Plaquenil 200 mg twice a day.,2.  Fosamax 170 mg once a week.,3.  Calcium and vitamin D complex twice daily.,4.  Folic acid 1 mg per day.,5.  Trilisate 1000 mg a day.,6.  K-Dur 20 mEq twice a day.,7.  Hydrochlorothiazide 15 mg once a day.,8.  Lopressor 50 mg one-half tablet twice a day.,9.  Trazodone 100 mg at bedtime.,10.  Prempro 0.625 mg per day.,11.  Aspirin 325 mg once a day.,12.  Lipitor 10 mg per day.,13.  Pepcid 20 mg twice a day.,14.  Reglan 10 mg before meals and at bedtime.,15.  Celexa 20 mg per day.,REVIEW OF SYSTEMS: , Noncontributory except for what was noted in the HPI and the remainder or complete review of systems is unremarkable.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Blood pressure 155/84, pulse 87, weight 223 pounds, and temperature 99.2.  GENERAL:  She is a well-developed, well-nourished female appearing her staged age.  She is alert, oriented, and cooperative.  HEENT:  Normocephalic and atraumatic.  There is no facial rash.  No oral lesions.  LUNGS:  Clear to auscultation.  CARDIOVASCULAR:  Regular rate and rhythm without murmurs, rubs or gallops.  EXTREMITIES:  No cyanosis or clubbing.  Sensory examination of the upper extremity decreased to light touch on the distal tips of the left second and third digits compared to the fifth digit.  Positive Tinel sign.  Full range of motion of the wrist with no evidence of motor atrophy or muscle loss.,LABORATORY DATA:  ,WBC 5100, hemoglobin 11.1, hematocrit 32.8, and platelets 200,000.  Westergren sedimentation rate of 47.  Urinalysis is negative for protein and blood.  Lupus serology is pending.,ASSESSMENT:,1.  Systemic lupus erythematosus that is chronically stable at this point.,2.  Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.,3.  Upper respiratory infection with cough, cold, and congestion.,RECOMMENDATIONS:,1.  The patient will have a trial of a resting wrist splint at night for the next 4 to 6 weeks.  If there is no improvement, the patient will return for corticosteroid injection of her carpal tunnel.,2.  Azithromycin 5-day dose pack.,3.  Robitussin Cough and Cold Flu to be taken twice a day.,4.  Atarax 25 mg at bedtime for sleep.,5.  The patient will return to the rheumatology clinic for a routine followup evaluation in 4 months.
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DESCRIPTION: Followup of left hand discomfort and systemic lupus erythematosus.  Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.

The situation involves a follow-up visit for a patient with systemic lupus erythematosus who is also experiencing carpal tunnel symptoms. The case requires management of chronic conditions and monitoring of sensory changes. However, the conditions are stable and being managed with planned interventions. There is no immediate life-threatening aspect indicated. Therefore, it is more of a routine management issue rather than a high-stakes situation.


Medical Specialty: Consult - History and Phy.
Sample Name: Prostate Adenocarcinoma

ADMISSION DIAGNOSIS:  ,Adenocarcinoma of the prostate.,HISTORY:,  The patient is a 71-year-old male whose personal physician, Dr. X identified a change in the patient's PSA from 7/2008 (4.2) to 4/2009 (10.5).  The patient underwent a transrectal ultrasound and biopsy and was found to have a Gleason 3+4 for a score of 7, 20% of the tissue removed from the left base.  The patient also had Gleason 6 in the right lobe, midportion, as well as the left apical portion.  He underwent a bone scan which was normal and cystoscopy which was normal and renal ultrasound that was normal.,SURGICAL HISTORY: , Appendectomy.,MEDICAL HISTORY:,  Atrial fibrillation.,MEDICATIONS:,  Coumadin and lisinopril.,SOCIAL HISTORY:  ,Smokes none.  Alcohol none.,ALLERGIES:,  NONE.,REVIEW OF SYSTEMS: , The patient relates no recent weight gain, weight loss, night sweats, fevers or chills.  Eyes:  No change in vision or diplopia.  Ears:  No tinnitus or vertigo.  Mouth:  No dysphagia.  Pulmonary:  No chronic cough or shortness of breath.  Cardiac:  No angina or palpitations.  GI:  No nausea, vomiting, diarrhea or constipation.  Musculoskeletal:  No arthritides or myalgias.  Hematopoietic:  No easy bleeding or bruising.  Skin:  No chronic ulcers or persistent itch.,PHYSICAL EXAMINATION:,GENERAL:  The patient is well developed and well nourished.,HEENT:  Head is normocephalic.  Eyes, pupils are equal.  Conjunctivae are pink.  Sclerae are anicteric.,NECK:  There is no adenopathy.,PULMONARY:  Respirations are unlabored.,HEART:  Regular rhythm.,ABDOMEN:  Liver, spleen, kidney, and bladder are not palpable.  There are no discernible masses.  There are no peritoneal signs.,GENITALIA:  The penis has no plaques.  Meatus is on the glans.  Scrotal skin is healthy.  Testicles are fair consistency.  Epididymides are nontender.,RECTAL:  The prostate is +1 to 2/4.  There are no areas that are suspicious for tumor.  Consistency is even.  Sidewalls are sharp.  Seminal vesicles are not palpable.,MUSCULOSKELETAL:  The upper and lower extremities are symmetric bilaterally.,NEUROLOGIC:  There are no gross focal neurologic abnormalities.,IMPRESSION:,1.  Adenocarcinoma of the prostate.,2.  Atrial fibrillation.,PLAN: , The patient's wife and I have discussed his treatment options, which include primarily radiation and surgery.  He has _________ surviving prostate cancer by Dr. Y.  He is aware of incontinency, both total and partial.  We discussed erectile dysfunction.  We have discussed bleeding, infection, injury to the rectum, injury to vessels and nerves, deep vein thrombosis, pulmonary embolus, MI, stroke, and death.  He had no questions at the conclusion of the conversation and he does know that in his age group, though a nerve-sparing procedure will be performed, preserving any erectile function is highly unlikely.  He had no questions at the conclusion of our last conversation.
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DESCRIPTION: Adenocarcinoma of the prostate.  The patient underwent a transrectal ultrasound and biopsy and was found to have a Gleason 3+4 for a score of 7, 20% of the tissue removed from the left base.

The patient has been diagnosed with prostate adenocarcinoma, a significant and potentially life-threatening condition, particularly at the diagnosed stage (Gleason score of 7), which indicates a moderate to high risk of progression. The stakes are high due to the nature of cancer and the potential outcomes of treatment, which also include risks of significant side effects such as incontinence and erectile dysfunction. Decisions made could greatly impact the patient's quality of life and health outcomes.


Medical Specialty: Surgery
Sample Name: Calcaneal Lengthening Osteotomy

PREOPERATIVE DIAGNOSES:,  Left calcaneal valgus split.,POSTOPERATIVE DIAGNOSES:,  Left calcaneal valgus split.,PROCEDURES:  ,1.  Left calcaneal lengthening osteotomy with allograft.,2.  Partial plantar fasciotomy.,3.  Posterior subtalar and tibiotalar capsulotomy.,4.  Short leg cast placed.,ANESTHESIA: , Surgery performed under general anesthesia.,TOURNIQUET TIME: , 69 minutes.,The patient in local anesthetic of 20 mL of 0.25% Marcaine plain.,COMPLICATIONS: , No intraoperative complications.,DRAINS:  ,None.,SPECIMENS: , None.,HISTORY AND PHYSICAL: , The patient is a 13-year-old female who had previous bilateral feet correction at 1 year of age.  Since that time, the patient has developed significant calcaneal valgus deformity with significant pain.  Radiographs confirmed collapse of the spinal arch, as well as valgus position of the foot.  Given the patient's symptoms, surgery is recommended for calcaneal osteotomy and Achilles lengthening.  Risks and benefits of surgery were discussed with the mother.  Risks of surgery include risk of anesthesia; infection; bleeding; changes in sensation in most of extremity; hardware failure; need for later hardware removal; possible nonunion; possible failure to correct all the deformity; and need for other surgical procedures.  The patient will need to be strict nonweightbearing for at least 6 weeks and wear a brace for up to 6 months.  All questions were answered and parents agreed to the above surgical plan.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room and placed supine on the operating table.  General anesthesia was then administered.  The patient received Ancef preoperatively.  A bump was placed underneath the left buttock.  A nonsterile tourniquet was placed on the upper aspect of the left thigh.  The extremity was then prepped and draped in a standard surgical fashion.  The patient had a previous incision along the calcaneocuboid lateral part of the foot.  This was marked and extended proximally through the Achilles tendon.  Extremity was wrapped in Esmarch.  Tourniquet inflation was noted to be 250 mmHg.  Decision was then made to protect the sural nerve.  There was one sensory nervous branch that did cross the field though it was subsequently sharply ligated because it was in the way.  Dissection was carried down to Achilles tendon, which was subsequently de-lengthened with the distal half performed down the lateral thigh.  Proximal end was tacked with an 0 Ethibond suture and subsequently repaired end-on-end at length with the heel in neutral.  Dissection was then carried on the lateral border of the foot with identification of the peroneal longus and valgus tendons, which were removed from the sheath and retracted dorsally.  At this time, we also noted that calcaneocuboid joint appeared to be fused.  The area between the anterior and middle facets were plicated on fluoroscopy for planned osteotomy.  This was performed with a saw.  After a partial plantar fasciotomy was performed, this was released off an abductor digiti minimi.  The osteotomy was completed with an osteotome and distracted with the lamina spreader.  A tricortical allograft was then shaped and subsequently impacted into this area.  Final positioning was checked with multiple views of fluoroscopy.  It was subsequently fixed using a 0.94 K-wire and drilled from the heel anteriorly.  A pin was subsequently bent and cut short at the level of the skin.  The wound was then irrigated with normal saline.  The Achilles was repaired with this tie.  Please note during the case, it was noted the patient had continued significant stiffness despite the Achilles lengthening.  A posterior capsulotomy of the tibiotalar and subtalar joints were performed with increased 10 degrees of dorsiflexion.  Wound was then closed using #2-0 Vicryl and #4-0 Monocryl.  The surgical field was irrigated with 0.25% Marcaine and subsequently injected with more Marcaine at the end of the case.  The wound was clean and dry and dressed with Steri-Strips and Xeroform.  Skin was dressed with Xeroform and 4 x 4's.  Everything was wrapped with 4 x 4's in sterile Webril.  The tourniquet was released after 69 minutes.  A short-leg cast was then placed with good return of capillary refill to his toes.  The patient tolerated the procedure well and was subsequently taken to the recovery room in stable condition.,POSTOPERATIVE PLAN: , The patient will be hospitalized overnight for elevation, ice packs, neurovascular checks, and pain control.  The patient to be strict nonweightbearing.  We will arrange for her to get a wheelchair.  The patient will then follow up in about 10 to 14 days for a cast check, as well as pain control.  The patient will need an AFO script at that time.  Intraoperative findings are relayed to the parents.
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DESCRIPTION: Left calcaneal lengthening osteotomy with allograft, partial plantar fasciotomy, posterior subtalar and tibiotalar capsulotomy, and short leg cast placed.

surgery, calcaneal lengthening, osteotomy, allograft, plantar fasciotomy, capsulotomy, calcaneal valgus split, partial plantar fasciotomy, short leg cast, achilles lengthening, calcaneal valgus, tourniquet, plantar, valgus, achilles, calcaneal,

The situation involves a surgical procedure on a 13-year-old female patient to correct a calcaneal valgus deformity. The stakes are high because it is an invasive procedure with risks such as anesthesia complications, infection, and other postoperative complications like nonunion or failure to correct the deformity. The surgery impacts the patient's immediate postoperative quality of life, requiring strict non-weight bearing and potentially affecting mobility for a period. While there were no intraoperative complications and the procedure appears successful, the long-term success and patient recovery are crucial. Moreover, the young age of the patient adds to the stakes involved given the implications for her future mobility and development.


Medical Specialty: Surgery
Sample Name: Sinus Fractures Repairs

PREOPERATIVE DIAGNOSES:,1.  Depressed anterior table frontal sinus fracture on the right side.,2.  Right nasoorbital ethmoid fracture.,3.  Right orbital blowout fracture with entrapped periorbita.,4.  Nasal septal and nasal pyramid fracture with nasal airway obstruction.,POSTOPERATIVE DIAGNOSES:,1.  Depressed anterior table frontal sinus fracture on the right side.,2.  Right nasoorbital ethmoid fracture.,3.  Right orbital blowout fracture with entrapped periorbita.,4.  Nasal septal and nasal pyramid fracture with nasal airway obstruction.,OPERATION:,1.  Open reduction and internal plate and screw fixation of depressed anterior table right frontal sinus.,2.  Transconjunctival exploration of right orbital floor with release of entrapped periorbita.,3.  Open reduction of nasal septum and nasal pyramid fracture with osteotomy.,ANESTHESIA:,  General endotracheal anesthesia.,PROCEDURE: , The patient was placed in the supine position.  Under affects of general endotracheal anesthesia, head and neck were prepped and draped with pHisoHex solution and draped in the appropriate sterile fashion.  A gull-wing incision was drawn over the forehead scalp.  Hair was removed along the suture line and incision was made to skin and subcutaneous tissue of the scalp down to, but not including the pericranium.  An inferiorly based forehead flap was then elevated to the superior orbital rim.  The depression of the anterior table of the frontal sinus was noted.  An incision was made more posterior creating an inferiorly based pericranial flap.  The supraorbital nerve was axing from the supraorbital foramen and the supraorbital foramen was converted to a groove in order to allow further inferior displacement and positioning of the forehead flap.  These allowed exposure of the medial orbital wall on the right side.  The displaced fractures of the right medial orbital wall were repositioned through coronal approach.  ,Further reduction of the nose intranasally also allowed the ethmoid fracture to be aligned more appropriately in the medial wall.  The anterior table fracture was satisfactorily reduced.  Multiple 1.3-mm screws and plate fixation were utilized to recontour the anterior forehead.  A mucocele was removed from the frontal sinus and there was no significant destruction of the posterior wall.  A sinus seeker was utilized and passed into the nasofrontal duct without difficulty.  It was felt that the frontal sinus obliteration would not be necessary.,At this point, the pericranial flap was folded in a fan-folded fashion on top of the plate and screw and hardware and fixed in position with the sutures to remain better contour of the forehead.  At this point, the nose was significantly shifted to the left and an open reduction of the nasal fracture was performed by osteotomies, which were made medially, laterally, and percutaneous transverse osteotomy of the nasal bone on the right side.  There is significant depression of the nasal bone on the left side.  A medial osteotomy was performed on the left side mobilizing nasal pyramid satisfactorily.  There is a high septal deviation, which would not allow complete correction of the deviation.  It was felt that this would best be left for a later date.  Open reduction rhinoplasty could be performed with spread of cartilage grafting in order to straighten the septum high dorsally.  Local infiltration anesthesia 1% Xylocaine with 1:100,000 epinephrine was infiltrated in the conjunctival fornix of the right lower eyelid as well as the inferior orbital rim.  An incision was made in the palpebral conjunctiva and capsular palpebral fascia beneath the tarsal plate preseptal approach to the inferior orbital rim was performed in this fashion.  Dissection proceeded down to the inferior orbital rim and subperiosteal dissection was performed over the orbital floor.  Hemostasis was achieved with electrocautery.  There was entrapped periorbita, which was released to the fractures, which were repositioned, but not fixed in position.  The forced ductions were performed, which demonstrated release of the periorbit satisfactorily.  The conjunctival incision was closed with an interrupted simple 6-0 plain gut suture.  The nasal pyramid was satisfactorily mobilized as well as the nasal septum and brought back to midline position with the help of a Boies elevator for the septum.  The coronal incision was closed with interrupted 3-0 PDS suture for the galea and deep subcutaneous tissue and the skin closed with interrupted surgical staples.  Nose was dressed with Steri-Strips.  Mastisol Orthoplast splint was prepared after the Doyle splints were placed in the nose and secured with 3-0 Prolene suture and the nose packed with two Kennedy Merocel sponges.  A supportive mildly compressive dressing with fluffs, Kerlix, and 4-inch Ace were applied.  The patient tolerated the procedure well and was returned to recovery room in satisfactory condition.
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DESCRIPTION: Open reduction and internal plate and screw fixation of depressed anterior table right frontal sinus, transconjunctival exploration of orbital floor, open reduction of nasal septum and nasal pyramid fracture with osteotomy.

surgery, frontal sinus, nasal septal, transconjunctival, anterior table, ethmoid, ethmoid fracture, gull-wing incision, nasal airway obstruction, nasal pyramid, nasoorbital, osteotomy, phisohex, periorbita, depressed anterior table, nasal pyramid fracture, sinus fractures, inferior orbital, pyramid fracture, entrapped periorbita, orbital, fractures, nasal, frontal, forehead, sinus,

Sinus fracture repairs involving ENT surgeries such as this one are complex and carry significant risks, including potential complications with vision, breathing, and aesthetic outcomes, particularly involving sensitive areas like the frontal sinus and orbit. The use of general anesthesia and detailed reconstruction procedures, such as open reduction and internal fixation with plates and screws, further indicates a high-stakes context. These factors imply a high degree of potential impact on the patient's health and quality of life if not executed correctly.


Medical Specialty: Discharge Summary
Sample Name: BRCA-2 mutation

DISCHARGE DIAGNOSES:,  BRCA-2 mutation.  ,HISTORY OF PRESENT ILLNESS:  ,The patient is a 59-year-old with a BRCA-2 mutation.  Her sister died of breast cancer at age 32 and her daughter had breast cancer at age 27.,PHYSICAL EXAMINATION:  ,The chest was clear.  The abdomen was nontender.  Pelvic examination shows no masses.  No heart murmur.  ,HOSPITAL COURSE:  ,The patient underwent surgery on the day of admission.  In the postoperative course she was afebrile and unremarkable.  The patient regained bowel function and was discharged on the morning of the fourth postoperative day.,OPERATIONS AND PROCEDURES: , Total abdominal hysterectomy/bilateral salpingo-oophorectomy with resection of ovarian fossa peritoneum en bloc on July 25, 2006.,PATHOLOGY: , A 105-gram uterus without dysplasia or cancer.,CONDITION ON DISCHARGE: , Stable.,PLAN:  ,The patient will remain at rest initially with progressive ambulation after.  She will avoid lifting, driving or intercourse.  She will call me if any fevers, drainage, bleeding, or pain.  Follow up in my office in four weeks.  Family history, social history, psychosocial needs per the social worker.,DISCHARGE MEDICATIONS: , Percocet 5 #40 one every 3 hours p.r.n. pain.
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DESCRIPTION: Discharge summary of a patient with a BRCA-2 mutation.

discharge summary, brca-2 mutation, brca-2, mutation, breast cancer, brca mutation, breast, postoperative, peritoneum, brca, discharge, cancer,

The discharge summary details a patient's surgery related to a BRCA-2 mutation and her stable condition upon discharge. While the patient has a genetic predisposition to cancer, at the time of discharge, there is no acute, life-threatening illness, as she is stable post-surgery with a clear plan for recovery. However, the genetic implications are significant for future health monitoring, making this a moderately high-stakes scenario regarding ongoing health vigilance.


Medical Specialty: ENT - Otolaryngology
Sample Name: Middle Ear Exploration

PREOPERATIVE DIAGNOSIS: , Right profound mixed sensorineural conductive hearing loss.,POSTOPERATIVE DIAGNOSIS:,  Right profound mixed sensorineural conductive hearing loss.,PROCEDURE PERFORMED:,  Right middle ear exploration with a Goldenberg TORP reconstruction.,ANESTHESIA:,  General ,ESTIMATED BLOOD LOSS:,  Less than 5 cc.,COMPLICATIONS:,  None.,DESCRIPTION OF FINDINGS:,  The patient consented to revision surgery because of the profound hearing loss in her right ear.  It was unclear from her previous operative records and CT scan as to whether or not she was a reconstruction candidate.  She had reports of stapes fixation as well as otosclerosis on her CT scan.,At surgery, she was found to have a mobile malleus handle, but her stapes was fixed by otosclerosis.  There was no incus.  There was no specific round window niche.  There was a very minute crevice; however, exploration of this area did not reveal a niche to a round window membrane.  The patient had a type of TORP prosthesis, which had tilted off the footplate anteriorly underneath the malleus handle.,DESCRIPTION OF THE PROCEDURE:,  The patient was brought to the operative room and placed in supine position.  The right face, ear, and neck prepped with ***** alcohol solution.  The right ear was draped in the sterile field.  External auditory canal was injected with 1% Xylocaine with 1:50,000 epinephrine.  A Fisch indwelling incision was made and a tympanomeatal flap was developed in a 12 o'clock to the 7 o'clock position.  Meatal skin was elevated, middle ear was entered.  This exposure included the oval window, round window areas.  There was a good cartilage graft in place and incorporated into the posterior superior ***** of the drum.  The previous prosthesis was found out of position as it had tilted out of position anteriorly, and there was no contact with the footplate.  The prosthesis was removed without difficulty.  The patient's stapes had an arch, but the ***** was atrophied.  Malleus handle was mobile.  The footplate was fixed.  Consideration have been given to performing a stapedectomy with a tissue seal and then returning later for prosthesis insertion; however, upon inspection of the round window area, there was found to be no definable round window niche, no round window membrane.  The patient was felt to have obliterated otosclerosis of this area along with the stapes fixation.  She is not considered to be a reconstruction candidate under the current circumstances.  No attempt was made to remove bone from the round window area.  A different style of Goldenberg TORP was placed on the footplate underneath the cartilage support in hopes of transferring some sound conduction from the tympanic membrane to the footplate.  The fit was secure and supported with Gelfoam in the middle ear.  The tympanomeatal flap was returned to anatomic position supported with Gelfoam saturated Ciprodex.  The incision was closed with #4-0 Vicryl and individual #5-0 nylon to the skin, and a sterile dressing was applied.
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DESCRIPTION: Right middle ear exploration with a Goldenberg TORP reconstruction.

ent - otolaryngology, conductive hearing loss, goldenberg, meatal skin, torp, torp reconstruction, ear, ear exploration, handle, malleus, otosclerosis, sensorineural, stapedectomy, tympanomeatal, middle ear exploration, hearing loss, malleus handle, middle ear, middle

The procedure described involves middle ear exploration and reconstruction due to hearing loss, which is important for improving or restoring hearing function in the patient. However, the situation doesn't imply immediate life-threatening conditions as there are no complications, and blood loss is minimal. While any surgical procedure has inherent risks, this specific surgery is not typically considered high-risk or high-stakes in comparison with emergencies or surgeries involving vital organs. The stakes here are more related to quality of life improvements rather than life-preserving measures.


Medical Specialty: Sleep Medicine
Sample Name: Sleep Study Interpretation

PROCEDURE:, Sleep study.,CLINICAL INFORMATION:, This patient is a 56-year-old gentleman who had symptoms of obstructive sleep apnea with snoring, hypertension. The test was done 01/24/06. The patient weighed 191 pounds, five feet, seven inches tall.,SLEEP QUESTIONNAIRE:, According to the patient's own estimate, the patient took about 15 minutes to fall asleep, slept for six and a half hours, did have some dreams. Did not wake up and the sleep was less refreshing. He was sleepy in the morning.,STUDY PROTOCOL:, An all night polysomnogram was recorded with a Compumedics E Series digital polysomnograph. After the scalp was prepared, Ag/AgCl electrodes were applied to the scalp according to the International 10-20 System. EEG was monitored from C4-A1, C3-A2, O2-A1 and O2-A1. EOG and EMG were continuously monitored by electrodes placed at the outer canthi and chin respectively. Nasal and oral airflow were monitored using a triple port Thermistor. Respiratory effort was measured by piezoelectric technology employing an abdominal and thoracic belt. Blood oxygen saturation was continuously monitored by pulse oximetry. Heart rate and rhythm were monitored by surface electrocardiography. Anterior tibialis EMG was studied by using surface mounted electrodes placed 5 cm apart on both legs. Body position and snoring level were also monitored.,TECHNICAL QUALITY OF STUDY:, Good.,ELECTROPHYSIOLOGIC MEASUREMENTS:, Total recording time 406 minutes, total sleep time 365 minutes, sleep latency 25.5 minutes, REM latency 49 minutes, _____ 90%, sleep latency measured 86%. _____ period was obtained. The patient spent 10% of the time awake in bed.,Stage I: 3.8,Stage II: 50.5,Stage III: 14%,Stage REM: 21.7%,The patient had relatively good sleep architecture, except for excessive waking.,RESPIRATORY MEASUREMENTS:, Total apnea/hypopnea 75, age index 12.3 per hour. REM age index 15 per hour. Total arousal 101, arousal index 15.6 per hour. Oxygen desaturation was down to 88%. Longest event 35 second hypopnea with an FiO2 of 94%. Total limb movements 92, PRM index 15.1 per hour. PRM arousal index 8.9 per hour.,ELECTROCARDIOGRAPHIC OBSERVATIONS:, Heart rate while asleep 60 to 64 per minute, while awake 70 to 78 per minute.,CONCLUSIONS:, Obstructive sleep apnea syndrome with moderately loud snoring and significant apnea/hypopnea index.,RECOMMENDATIONS:,AXIS B: Overnight polysomnography.,AXIS C: Hypertension.,The patient should return for nasal CPAP titration. Sleep apnea if not treated, may lead to chronic hypertension, which may have cardiovascular consequences. Excessive daytime sleepiness, dysfunction and memory loss may also occur.
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DESCRIPTION: Sleep study - patient with symptoms of obstructive sleep apnea with snoring.

sleep medicine, sleep study, obstructive sleep apnea, snoring, hypertension, polysomnogram, compumedics, polysomnograph, ag/agcl electrodes, triple port thermistor, rem, latency, polysomnography, cpap titration, sleep latency, apnea, sleep, obstructive, index,

This situation involves the interpretation of a sleep study that indicates the presence of obstructive sleep apnea (OSA) and associated recommendations. OSA is a serious condition that can lead to significant health risks, including cardiovascular problems, if left untreated. The medical practitioner's interpretation and subsequent management plan are crucial for the patient's health. However, the urgency is not immediate unless the patient is experiencing severe symptoms or complications. The stakes are moderate because it directly relates to the patient's long-term health outcomes, but there is typically time to manage and treat the condition after the sleep study results are obtained.


Medical Specialty: Emergency Room Reports
Sample Name: MRSA Infection - ER Visit

HISTORY OF PRESENT ILLNESS:,  A 14-day-old was seen by private doctor because of blister.  On Friday, she was noted to have a small blister near her umbilicus.  They went to their doctor on Saturday, culture was drawn.  It came back today, growing MRSA.  She has been doing well.  They put her on bacitracin ointment near the umbilicus.  That has about healed up.  However today, they noticed a small blister on her left temporal area.  They called the private doctor.  They direct called the Infectious Disease doctor here and was asked that they come into the hospital.  Mom states she has been diagnosed with MRSA on her buttocks as well and is on some medications.  The child has not had any fever.  She has not been lethargic or irritable.  She has been eating well up to 2 ounces every feed.  Eating well and sleeping well.  No other changes have been noted.,PAST MEDICAL HISTORY:,  She was born full term.  No complications.  Home with mom.  No hospitalization, surgeries, allergies.,MEDICATIONS: , As noted.,IMMUNIZATIONS: , Up-to-date.,FAMILY HISTORY: , Negative.,SOCIAL HISTORY: , No ill contacts.  No travel or changes in living condition.,REVIEW OF SYSTEMS:  ,Ten systems were asked, all of them were negative except as noted above.,PHYSICAL EXAMINATION:  ,GENERAL:  Awake, alert female, no acute distress at this time.,HEENT:  Fontanelle soft and flat.  PERRLA.  EOMI.  Conjunctivae are clear.  TMS are clear.  Nares are clear.  Mucous membranes pinks and moist.  Throat clear.  No oral lesions.,NECK:  Supple.,LUNGS:  Clear.,HEART:  Regular rate and rhythm.  Normal S1, S2.  No murmur.,ABDOMEN:  Soft, nontender.  Positive bowel sounds.  No guarding, no rebound.  No rashes seen.,EXTREMITIES:  Capillary refill is brisk.  Good distal pulses.,NEUROLOGIC:  Cranial nerves II through XII intact.  5/5 strength in all extremities.,SKIN:  Her umbilicus looks completely clear.  There is no evidence of erythema.  The area that the parents point where the blister was, appears to be well healed.  There is no evidence of lesion noted, at this time.  On her left temple area and just inside her hairline, there is a small vesicle.  It is not a pustule.  It is almost flat and it has minimal fluid underneath that.  There is no surrounding erythema, tenderness.  I have inspected the body, head to toe.  No other areas of lesions seen.,EMERGENCY DEPARTMENT COURSE: , I spoke with Infectious Disease, Dr. X.  He states, we should treat for MRSA with Bactrim p.o.  There has been no evidence of jaundice with this little girl.  Hibiclens and Bactroban.  I spoke with Dr. X's associate to call back after Dr. X recommended a Herpes culture be done, just for completeness and that was done.  Blood culture was done here to make sure she did not have MRSA in her blood, which clinically, she does not appear to have.  She was discharged in stable condition.,IMPRESSION: , Methicillin-resistant Staphylococcus aureus infection.,PLAN: ,  MRSA Instructions were given as above and antibiotics were prescribed.  To follow up with their doctor.
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DESCRIPTION: Methicillin-resistant Staphylococcus aureus (MRSA) infection.  A 14-day-old was seen by private doctor because of blister.

The case involves a 14-day-old infant who has a MRSA infection, which can be serious due to the infant's age and the potential for rapid spread of infection. However, the child is currently doing well with no fever, lethargy, and is eating properly. The ER visit includes consultation with an Infectious Disease specialist, culture tests, and a conservative treatment plan involving antibiotics. They are being followed up with outpatient care, which indicates the situation is under control. Nonetheless, MRSA in newborns is a significant concern due to their developing immune systems, making it moderately high-stakes.


Medical Specialty: Rheumatology
Sample Name: Rheumatoid Arthritis - H&P

CHIEF COMPLAINT:,  This 26 year old male presents today for treatment of suspected rheumatoid arthritis.  Associated signs and symptoms include aching, joint pain, and symmetrical joint swelling bilateral.  Patient denies any previous history, related trauma or previous treatments for this condition.  Condition has existed for 2 weeks.  He indicates the problem location is the right hand and left hand.  Patient indicates no modifying factors.  Severity of condition is slowly worsening.  Onset was unknown.,ALLERGIES:,  Patient admits allergies to aspirin resulting in GI upset, disorientation.,MEDICATION HISTORY: , Patient is currently taking amoxicillin-clavulanate 125 mg-31.25 mg tablet, chewable medication was prescribed by A. General Practitioner MD, Adrenocot 0.5 mg tablet medication was prescribed by A. General Practitioner MD.,PAST MEDICAL HISTORY:,  Past medical history is unremarkable.,PAST SURGICAL HISTORY: , Patient admits past surgical history of (+) appendectomy in 1989.,FAMILY HISTORY: , Patient admits a family history of rheumatoid arthritis associated with maternal grandmother.,SOCIAL HISTORY:  ,Patient denies alcohol use.  Patient denies illegal drug use.  Patient denies STD history.  Patient denies tobacco use.,REVIEW OF SYSTEMS: , Neurological: (+) paralysis Musculoskeletal: (+) joint pain (+) joint swelling (+) stiffness Cardiovascular: (+) ankle swelling Neurological: (-) numbness,Musculoskeletal: (-) back pain (chronic) (-) decreased ROM (-) episodic weakness,Cardiovascular: (-) chest pressure Respiratory: (-) breathing difficulties, respiratory symptoms (-) sleep apnea,PHYSICAL EXAM: , BP Standing:  120/84 HR:  79 Temp:  98.6 Height:  5 ft.  8 in.  Weight:  168 lbs.  Patient is a 26 year old male who appears pleasant, in no apparent distress, his given age, well developed, well nourished and with good attention to hygiene and body habitus.  Skin:  No skin rash, subcutaneous nodules, lesions or ulcers observed.  Palpation of skin shows no abnormalities.,HEENT:  Inspection of head and face shows no abnormalities.  Hair growth and distribution is normal.  Examination of scalp shows no abnormalities.  Conjunctiva and lids reveal no signs or symptoms of infection.  Pupil exam reveals round and reactive pupils without afferent pupillary defect.  Ocular motility exam reveals gross orthotropia with full ductions and versions bilateral.  Bilateral retinas reveal normal color, contour, and cupping.  Inspection of ears reveals no abnormalities.  Otoscopic examination reveals no abnormalities.  Examination of oropharynx reveals no abnormalities and tissues pink and moist.  ENT:  Inspection of ears reveals no abnormalities.  Examination of larynx reveals no abnormalities.  Inspection of nose reveals no abnormalities.,Neck:  Neck exam reveals neck supple and trachea that is midline, without adenopathy or crepitance palpable.  Thyroid examination reveals no abnormalities and smooth and symmetric gland with no enlargement, tenderness or masses noted.  Lymphatic:  Neck lymph nodes are normal.,Respiratory:  Assessment of respiratory effort reveals even respirations without use of accessory muscles and no intercostal retractions noted.  Chest inspection reveals chest configuration non-hyperinflated and symmetric expansion.  Auscultation of lungs reveals clear lung fields and no rubs noted.,Cardiovascular:  Heart auscultation reveals normal S1 and S2 and no murmurs, gallop, rubs or clicks.  Examination of peripheral vascular system reveals full to palpation, varicosities absent, extremities warm to touch and no edema.,Abdomen:  Abdominal contour is slightly rounded.  Abdomen soft, nontender, bowel sounds present x 4 without palpable masses.  Palpation of liver reveals no abnormalities.  Palpation of spleen reveals no abnormalities.,Musculoskeletal:  Gait and station examination reveals normal arm swing, with normal heel-toe and tandem walking.  Inspection and palpation of bones, joints and muscles is unremarkable.  Muscle strength is 5/5 for all groups tested.  Muscle tone is normal.,Neurologic/Psychiatric:  Psychiatric:  Oriented to person, place and time.  Mood and affect normal and appropriate to situation.  Testing of cranial nerves reveals no deficits.  Coordination is good.  Touch, pin, vibratory and proprioception sensations are normal.  Deep tendon reflexes normal.,TEST & X-RAY RESULTS:,  Rheumatoid factor:  52 U/ml.  Sed rate:  31 mm/hr.  C4 complement:  19 mg/dl.,IMPRESSION: , Rheumatoid arthritis.,PLAN:,  ESR ordered; automated.  Ordered RBC.  Ordered quantitative rheumatoid factor.  Return to clinic in 2 week (s).,PRESCRIPTIONS:,  Vioxx Dosage:  12.5 mg tablet Sig:  BID Dispense:  30 Refills:  2 Allow Generic:  No
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DESCRIPTION: Patient presents for treatment of suspected rheumatoid arthritis.

This scenario involves a clinical case of suspected rheumatoid arthritis in a young adult patient. The stakes are not particularly high as this condition, while chronic and potentially debilitating, is not immediately life-threatening, and appropriate management can significantly improve quality of life. The situation involves diagnostic assessment and initiation of treatment, which requires careful medical evaluation but does not involve emergency intervention or acute care relat**ed stakes. The patient is also scheduled for follow-up visit in two weeks, indicative of a non-urgent progression in care. Thus, the stakes primarily involve managing a chronic condition rather than addressing a critical or emergency health issue.


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

Medical Specialty: Orthopedic
Sample Name: MRI Spine - Epidural Lipoma

CC:, Progressive lower extremity weakness.,HX: ,This 54 y/o RHF presented on 7/3/93 with a 2 month history of lower extremity weakness. She was admitted to a local hospital on 5/3/93 for a 3 day h/o of progressive BLE weakness associated with incontinence and BLE numbness. There was little symptom of upper extremity weakness at that time, according to the patient. Her evaluation was notable for a bilateral L1 sensory level and 4/4 strength in BLE. A T-L-S Spine MRI revealed a T4-6 lipomatosis with anterior displacement of the cord without cord compression. CSF analysis yielded: opening pressure of 14cm H20, protein 88, glucose 78, 3 lymphocytes and 160 RBC, no oligoclonal bands or elevated IgG index, and negative cytology. Bone marrow biopsy was negative. B12, Folate, and Ferritin levels were normal. CRP 5.2 (elevated). ANA was positive at 1:5,120 in speckled pattern. Her hospital course was complicated by deep venous thrombosis, which recurred after heparin was stopped to do the bone marrow biopsy. She was subsequently placed on Coumadin. EMG/NCV testing revealed " lumbosacral polyradiculopathy with axonal degeneration and nerve conduction block." She was diagnosed with atypical Guillain-Barre vs. polyradiculopathy and received a single course of Decadron; and no plasmapheresis or IV IgG. She was discharged home o 6/8/93.,She subsequently did not improve and after awaking from a nap on her couch the day of presentation, 7/3/93, she found she was paralyzed from the waist down. There was associated mild upper lumbar back pain without radiation. She had had no bowel movement or urination since that time. She had no recent trauma, fever, chills, changes in vision, dysphagia or upper extremity deficit.,MEDS:, Coumadin 7.5mg qd, Zoloft 50mg qd, Lithium 300mg bid.,PMH:, 1) Bi-polar Affective Disorder, dx 1979 2) C-section.,FHX:, Unremarkable.,SHX:, Denied Tobacco/ETOH/illicit drug use.,EXAM: ,BP118/64, HR103, RR18, Afebrile.,MS: ,A&O to person, place, time. Speech fluent without dysarthria. Lucid thought processes.,CN: ,Unremarkable.,MOTOR:, 5/5 strength in BUE. Plegic in BLE. Flaccid muscle tone.,SENSORY:, L1 sensory level (bilaterally) to PP and TEMP, without sacral sparing. Proprioception was lost in both feet.,CORD: ,Normal in BUE.,Reflexes were 2+/2+ in BUE. They were not elicited in BLE. Plantar responses were equivocal, bilaterally.,RECTAL: ,Poor rectal tone. stool guaiac negative. She had no perirectal sensation.,COURSE:, CRP 8.8 and ESR 76. FVC 2.17L. WBC 1.5 (150 bands, 555 neutrophils, 440 lymphocytes and 330 monocytes), Hct 33%, Hgb 11.0, Plt 220K, MCV 88, GS normal except for slightly low total protein (8.0). LFT were normal. Creatinine 1.0. PT and PTT were normal. ABCG 7.46/25/79/96% O2Sat. UA notable for 1+ proteinuria. EKG normal.,MRI L-spine, 7/3/93, revealed an area of abnormally increased T2 signal extending from T12 through L5. This area causes anterior displacement of the spinal cord and nerve roots. The cauda equina are pushed up against the posterior L1 vertebral body. There bilaterally pulmonary effusions. There is also abnormally increased T2 signal in the center of the spinal cord extending from the mid thoracic level through the conus. In addition, the Fila Terminale appear thickened. There is increased signal in the T3 vertebral body suggestion a hemangioma. The findings were felt consistent with a large epidural lipoma displacing the spinal cord anteriorly. there also appeared spinal cord swelling and increased signal within the spinal cord which suggests an intramedullary process.,CSF analysis revealed: protein 1,342, glucose 43, RBC 4,900, WBC 9. C3 and C$ complement levels were 94 and 18 respectively (normal) Anticardiolipin antibodies were negative. Serum Beta-2 microglobulin was elevated at 2.4 and 3.7 in the CSF and Serum, respectively. It was felt the patient had either a transverse myelitis associated with SLE vs. partial cord infarction related to lupus vasculopathy or hypercoagulable state. She was place on IV Decadron. Rheumatology felt that a diagnosis of SLE was likely. Pulmonary effusion analysis was consistent with an exudate. She was treated with plasma exchange and place on Cytoxan.,On 7/22/93 she developed fever with associated proptosis and sudden loss of vision, OD. MRI Brain, 7/22/93, revealed a 5mm thick area of intermediate signal adjacent to the posterior aspect of the right globe, possibly representing hematoma. Ophthalmology felt she had a central retinal vein occlusion; and it was surgically decompressed.,She was placed on prednisone on 8/11/93 and Cytoxan was started on 8/16/93. She developed a headache with meningismus on 8/20/93. CSF analysis revealed: protein 1,002, glucose2, WBC 8,925 (majority were neutrophils). Sinus CT scan negative. She was placed on IV Antibiotics for presumed bacterial meningitis. Cultures were subsequently negative. She spontaneously recovered. 8/25/93, cisternal tap CSF analysis revealed: protein 126, glucose 35, WBC 144 (neutrophils), RBC 95, Cultures negative, cytology negative. MRI Brain scan revealed diffuse leptomeningeal enhancement in both brain and spinal canal.,DSDNA negative. She developed leukopenia in 9/93, and she was switched from Cytoxan to Imuran. Her LFT's rose and the Imuran was stopped and she was placed back on prednisone.,She went on to have numerous deep venous thrombosis while on Coumadin. This required numerous hospital admissions for heparinization. Anticardiolipin antibodies and Protein C and S testing was negative.
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DESCRIPTION: MRI Spine - T12-L5 epidural lipoma and thoracic spinal cord infarction vs. transverse myelitis.

The situation involves a complex medical case with significant health implications. The patient is experiencing paralysis, potential complications from spinal cord issues, and involvement of multiple organ systems, which may be related to a likely diagnosis of Systemic Lupus Erythematosus (SLE). The patient's condition has led to multiple serious symptoms, including paralysis and vision loss, requiring intensive investigation and treatment involving steroids, antibiotics, Cytoxan, Prednisone, and plasma exchange. Given the serious nature of the symptoms, the impact on the patient's quality of life, and the involvement of multiple specialists for diagnosis and management, the situation is high-stakes. The patient's life and long-term health outcomes are significantly affected by the decisions and treatments being made.


Medical Specialty: Discharge Summary
Sample Name: Abscess with Cellulitis - Discharge Summary

ADMITTING DIAGNOSIS:,  Abscess with cellulitis, left foot.,DISCHARGE DIAGNOSIS:,  Status post I&D, left foot.,PROCEDURES:,  Incision and drainage, first metatarsal head, left foot with culture and sensitivity.,HISTORY OF PRESENT ILLNESS:,  The patient presented to Dr. X's office on 06/14/07 complaining of a painful left foot.  The patient had been treated conservatively in office for approximately 5 days, but symptoms progressed with the need of incision and drainage being decided.,MEDICATIONS:,  Ancef IV.,ALLERGIES:,  ACCUTANE.,SOCIAL HISTORY:,  Denies smoking or drinking.,PHYSICAL EXAMINATION: , Palpable pedal pulses noted bilaterally.  Capillary refill time less than 3 seconds, digits 1 through 5 bilateral.  Skin supple and intact with positive hair growth.  Epicritic sensation intact bilateral.  Muscle strength +5/5, dorsiflexors, plantar flexors, invertors, evertors.  Left foot with erythema, edema, positive tenderness noted, left forefoot area.,LABORATORY: , White blood cell count never was abnormal.  The remaining within normal limits.  X-ray is negative for osteomyelitis.  On 06/14/07, the patient was taken to the OR for incision and drainage of left foot abscess.  The patient tolerated the procedure well and was admitted and placed on vancomycin 1 g q.12h after surgery and later changed Ancef 2 g IV every 8 hours.  Postop wound care consists of Aquacel Ag and dry dressing to the surgical site everyday and the patient remains nonweightbearing on the left foot.  The patient progressively improved with IV antibiotics and local wound care and was discharged from the hospital on 06/19/07 in excellent condition.,DISCHARGE MEDICATIONS: , Lorcet 10/650 mg, dispense 24 tablets, one tablet to be taken by mouth q.6h as needed for pain.  The patient was continued on Ancef 2 g IV via PICC line and home health administration of IV antibiotics.,DISCHARGE INSTRUCTIONS: , Included keeping the foot elevated with long periods of rest.  The patient is to wear surgical shoe at all times for ambulation and to avoid excessive ambulation.  The patient to keep dressing dry and intact, left foot.  The patient to contact Dr. X for all followup care, if any problems arise.  The patient was given written and oral instruction about wound care before discharge.  Prior to discharge, the patient was noted to be afebrile.  All vitals were stable.  The patient's questions were answered and the patient was discharged in apparent satisfactory condition.  Followup care was given via Dr. X' office.
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DESCRIPTION: Incision and drainage, first metatarsal head, left foot with culture and sensitivity.

discharge summary, accutane, metatarsal head left foot, abscess with cellulitis, culture and sensitivity, incision and drainage, metatarsal head, foot, cellulitis, ancef, abscess, incision, drainage,

The discharge summary indicates that the patient had a medical procedure (incision and drainage) for an abscess with cellulitis. The condition required surgical intervention and subsequent antibiotic treatment, both in-hospital and post-discharge, via a PICC line, which signifies some level of seriousness. However, the patient was discharged in excellent condition and only follow-up care was needed, suggesting that the immediate risk has been mitigated. The absence of abnormal lab results and stabilization of vital signs further reduces the stakes. The need for proper home care and potential for complications if instructions are not followed adds some level of concern, but it is not life-threatening at this stage.


Medical Specialty: Orthopedic
Sample Name: Endoscopic Carpal Tunnel & de Quervain's Release

PREOPERATIVE DIAGNOSIS:  ,1.  Left carpal tunnel syndrome.,2.  de Quervain's tenosynovitis.,POSTOPERATIVE DIAGNOSIS:,  ,1.  Left carpal tunnel syndrome.,2.  de Quervain's tenosynovitis.,OPERATIONS PERFORMED:  ,1.  Endoscopic carpal tunnel release.,2.  de Quervain's release.,ANESTHESIA:,  I.V. sedation and local (1% Lidocaine).,ESTIMATED BLOOD LOSS:,  Zero.,COMPLICATIONS:,  None.,PROCEDURE IN DETAIL:  ,ENDOSCOPIC CARPAL TUNNEL RELEASE:,  With the patient under adequate anesthesia, the upper extremity was prepped and draped in a sterile manner.  The arm was exsanguinated.  The tourniquet was elevated at 290 mm/Hg.  Construction lines were made on the left palm to identify the ring ray.  A transverse incision was made in the wrist, between FCR and FCU, one fingerbreadth proximal to the interval between the glabrous skin of the palm and normal forearm skin.  Blunt dissection exposed the antebrachial fascia.  Hemostasis was obtained with bipolar cautery.  A distal-based window in the antebrachial fascia was then fashioned.  Care was taken to protect the underlying contents.  A proximal forearm fasciotomy was performed under direct vision.  A synovial elevator was used to palpate the undersurface of the transverse carpal ligament, and synovium was elevated off this undersurface.  Hamate sounds were then used to palpate the hook of hamate.  The endoscopic instrument was then inserted into the proximal incision.  The transverse carpal ligament was easily visualized through the portal.  Using palmar pressure, the transverse carpal ligament was held against the portal as the instrument was inserted down the transverse carpal ligament to the distal end.,The distal end of the transverse carpal ligament was then identified in the window.  The blade was then elevated, and the endoscopic instrument was withdrawn, dividing the transverse carpal ligament under direct vision.  After complete division o the transverse carpal ligament, the instrument was reinserted.  Radial and ulnar edges of the transverse carpal ligament were identified, and complete release was confirmed.,The wound was then closed with running subcuticular stitch.  Steri-Strips were applied, and sterile dressing was applied over the Steri-Strips.  The tourniquet was deflated.  The patient was awakened from anesthesia and returned to the Recovery Room in satisfactory condition, having tolerated the procedure well.,DE QUERVAIN'S RELEASE: , With the patient under adequate regional anesthesia applied by surgeon using 1% plain Xylocaine, the upper extremity was prepped and draped in a sterile manner.  The arm was exsanguinated.  The tourniquet was elevated to 290 mm/Hg.  A transverse incision was then made over the radial aspect of the wrist overlying the first dorsal tunnel.  Using blunt dissection, the radial sensory nerve branches were dissected and retracted out of the operative field.  The first dorsal tunnel was then identified.  The first dorsal tunnel was incised along the dorsal ulnar border, completely freeing the stenosing tenosynovitis (de Quervain's release).  EPB and APL tendons were inspected and found to be completely free.  The radial sensory nerve was inspected and found to be without damage.,The skin was closed with a running 3-0 Prolene subcuticular stitch and Steri-Strips were applied and, over the Steri-Strips, a sterile dressing, and, over the sterile dressing, a volar splint with the hand in safe position.  The tourniquet was deflated.  The patient was returned to the holding area in satisfactory condition, having tolerated the procedure well.
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DESCRIPTION: Endoscopic carpal tunnel release and de Quervain's release. Left carpal tunnel syndrome and de Quervain's tenosynovitis.

orthopedic, de quervain's tenosynovitis, de quervain's release, carpal tunnel syndrome, carpal tunnel release, endoscopic carpal tunnel release, tunnel, transverse, carpal, tourniquet, endoscopic,

The surgical procedure described involves two relatively common orthopedic operations: endoscopic carpal tunnel release and de Quervain's release. These procedures are generally considered routine and are performed frequently on patients with these diagnoses. The operations were completed without complications, and the estimated blood loss was zero, which is expected for such minimally invasive procedures. Furthermore, the patient was stable and in satisfactory condition postoperatively. While any surgery has inherent risks and requires skill and precision, these specific procedures are less complex compared to more extensive orthopedic surgeries. Thus, the stakes are not extremely high compared to other medical scenarios where the risk to the patient could be significantly greater.


Medical Specialty: Surgery
Sample Name: Plantar Fasciotomy

PREOPERATIVE DIAGNOSIS:,  Plantar fascitis, left foot.,POSTOPERATIVE DIAGNOSIS: , Plantar fascitis, left foot.,PROCEDURE PERFORMED: , Partial plantar fasciotomy, left foot.,ANESTHESIA:,  10 cc of 0.5% Marcaine plain with TIVA.,HISTORY:  ,This 35-year-old Caucasian female presents to ABCD General Hospital with above chief complaint.  The patient states she has extreme pain with plantar fascitis in her left foot and has attempted conservative treatment including orthotics without long-term relief of symptoms and desires surgical treatment.  The patient has been NPO since mid night.  Consent is signed and in the chart.  No known drug allergies.,Details Of Procedure:  An IV was instituted by the Department of Anesthesia in the preoperative holding area.  The patient was transported to the operating room and placed on the operating table in supine position with a safety belt across the stomach.  Copious amounts of Webril were placed on the left ankle followed by blood pressure cuff.  After adequate sedation by the Department of Anesthesia, a total of 10 cc of 0.5% Marcaine plain was injected into the surgical site both medially and laterally across the plantar fascia.  The foot was then prepped and draped in the usual sterile orthopedic fashion.  An Esmarch bandage was applied for exsanguination and the pneumatic ankle tourniquet was inflated to 250 mmHg.  The foot was then reflected on the operating, stockinet reflected, and the foot cleansed with a wet and dry sponge.  Attention was then directed to the plantar medial aspect of the left heel.  An approximately 0.75 cm incision was then created in the plantar fat pad over the area of maximal tenderness.,The incision was then deepened with a combination of sharp and blunt dissection until the plantar fascia was palpated.  A #15 blade was then used to transect the medial and central bands of the plantar fascia.  Care was taken to preserve the lateral fibroids.  The foot was dorsiflexed against resistance as the fibers were released and there was noted to be increased laxity after release of the fibers on the plantar aspect of the foot indicating that plantar fascia has in fact been transacted.  The air was then flushed with copious amounts of sterile saline.  The skin incision was then closed with #3-0 nylon in simple interrupted fashion.  Dressings consisted of #0-1 silk, 4 x 4s, Kling, Kerlix, and Coban.  The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted throughout all digits of the left foot.  The patient tolerated the above procedure and anesthesia well without complications.  The patient was transported to the PACU with vital signs stable and vascular status intact to the left foot.  Intraoperatively, an additional 80 cc of 1% lidocaine was injected for additional anesthesia in the case.  The patient is to be nonweightbearing on the left lower extremity with crutches.  The patient is given postoperative pain prescriptions for Vicodin ES, one q3-4h. p.o. p.r.n. for pain as well as Celebrex 200 mg one p.o. b.i.d.  The patient is to follow-up with Dr. X as directed.
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DESCRIPTION: Plantar fascitis, left foot.  Partial plantar fasciotomy.

surgery, foot, plantar fasciotomy, plantar fascitis, plantar fascia, plantar, fasciotomy, ankle, medially, fascitis, fascia

The procedure described is a partial plantar fasciotomy, which is a surgical intervention performed to relieve pain caused by plantar fasciitis in cases where conservative treatments have failed. While the procedure itself is relatively routine and commonly performed in a controlled surgical environment, it involves anesthesia, surgical incision, and the potential for complications, such as infection or issues with wound healing. Given that it is a surgical procedure and involves significant post-operative care, including being non-weightbearing and managing pain, it carries inherent risks typical of surgical interventions, albeit less critical than more complex or life-threatening surgeries.