Medical Specialty: Radiology
Sample Name: Radiofrequency Thermocoagulation

PROCEDURE: , Right sacral alar notch and sacroiliac joint/posterior rami radiofrequency thermocoagulation.,ANESTHESIA:  ,Local sedation.,VITAL SIGNS: , See nurse's notes.,COMPLICATIONS: , None.,DETAILS OF PROCEDURE: , INT was placed.  The patient was in the operating room in the prone position.  The back prepped with Betadine.  The patient was given sedation and monitored.  Under fluoroscopy, the right sacral alar notch was identified.  After placement of a 20-gauge, 10 cm SMK needle into the notch, a positive sensory, negative motor stimulation was obtained.  Following negative aspiration, 5 cc of 0.5% of Marcaine and 20 mg of Depo-Medrol were injected.  Coagulation was then carried out at 90oC for 90 seconds.  The SMK needle was then moved to the mid-inferior third of the right sacroiliac joint.  Again the steps dictated above were repeated.,The above was repeated for the posterior primary ramus branch right at S2 and S3 by stimulating along the superior lateral wall of the foramen; then followed by steroid injected and coagulation as above.,There were no complications.  The patient was returned to outpatient recovery in stable condition.
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DESCRIPTION: Right sacral alar notch and sacroiliac joint/posterior rami radiofrequency thermocoagulation.

radiology, posterior rami, sacroiliac joint, sacral alar notch, radiofrequency thermocoagulation, thermocoagulation, radiofrequency, sacroiliac, sacral, alar, notch

The procedure described is a medical intervention involving radiofrequency thermocoagulation, which is often used to reduce pain by targeting specific nerves. The stakes here could involve the risk of complications or suboptimal results impacting patient health and safety; however, the procedure was performed without complications, and the patient was stable post-procedure. Although important, this procedure is relatively routine within radiology, using common techniques and sedation. Thus, while it is critical for patient care, it does not involve life-threatening risks or highly complex unknowns, suggesting the stakes are moderate.


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

Medical Specialty: Radiology
Sample Name: Chest Pulmonary Angio

EXAM: , CTA chest pulmonary angio.,REASON FOR EXAM: , Evaluate for pulmonary embolism.,TECHNIQUE: , Postcontrast CT chest pulmonary embolism protocol, 100 mL of Isovue-300 contrast is utilized.,FINDINGS: , There are no filling defects in the main or main right or left pulmonary arteries.  No central embolism.  The proximal subsegmental pulmonary arteries are free of embolus, but the distal subsegmental and segmental arteries especially on the right are limited by extensive pulmonary parenchymal, findings would be discussed in more detail below.  There is no evidence of a central embolism.,As seen on the prior examination, there is a very large heterogeneous right chest wall mass, which measures at least 10 x 12 cm based on axial image #35.  Just superior to the mass is a second heterogeneous focus of neoplasm measuring about 5 x 3.3 cm.  Given the short interval time course from the prior exam, dated 01/23/09, this finding has not significantly changed.  However, there is considerable change in the appearance of the lung fields.  There are now bilateral pleural effusions, small on the right and moderate on the left with associated atelectasis.  There are also extensive right lung consolidations, all new or increased significantly from the prior examination.  Again identified is a somewhat spiculated region of increased density at the right lung apex, which may indicate fibrosis or scarring, but the possibility of primary or metastatic disease cannot be excluded.  There is no pneumothorax in the interval.,On the mediastinal windows, there is presumed subcarinal adenopathy, with one lymph node measuring roughly 12 mm suggestive of metastatic disease here.  There is aortic root and arch and descending thoracic aortic calcification.  There are scattered regions of soft plaque intermixed with this.  The heart is not enlarged.  The left axilla is intact in regards to adenopathy.  The inferior thyroid appears unremarkable.,Limited assessment of the upper abdomen discloses a region of lower density within the right hepatic lobe, this finding is indeterminate, and if there is need for additional imaging in regards to hepatic metastatic disease, follow up ultrasound.  Spleen, adrenal glands, and upper kidneys appear unremarkable.  Visualized portions of the pancreas are unremarkable.,There is extensive rib destruction in the region of the chest wall mass.  There are changes suggesting prior trauma to the right clavicle.,IMPRESSION:,1.  Again demonstrated is a large right chest wall mass.,2.  No central embolus, distal subsegmental and segmental pulmonary artery branches are in part obscured by the pulmonary parenchymal findings, are not well assessed.,3.  New bilateral pleural effusions and extensive increasing consolidations and infiltrates in the right lung.,4.  See above regarding other findings.
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DESCRIPTION: Postcontrast CT chest pulmonary embolism protocol, 100 mL of Isovue-300 contrast is utilized.

radiology, chest pulmonary embolism, chest pulmonary embolism protocol, bilateral pleural effusions, chest wall mass, metastatic disease, pulmonary, isovue, subsegmental, metastatic, disease, mass, lung, embolism, chest, angio

The described radiology report identifies key findings about a large right chest wall mass, potential metastatic disease, and changes in lung tissue including consolidations and pleural effusions. Although no central pulmonary embolism is found, the presence of a mass and possible metastasis with significant changes in the lungs indicates a serious medical condition that could have substantial implications for the patient's health and require urgent medical interventions.

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Medical Specialty: Obstetrics / Gynecology
Sample Name: TAH & Salpingo-oophorectomy & Lysis of Adhesions

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

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

The procedure described involves a total abdominal hysterectomy, salpingo-oophorectomy, and lysis of bowel adhesions. This is a significant surgical intervention typically performed to address issues like chronic pelvic pain and endometriosis. The complexity of the surgery, which includes dissection and resection, indicates potential risks such as significant blood loss (estimated at 400 cc), potential injury to surrounding organs, and complications from anesthesia. These factors elevate the stakes for both the patient and the medical team given the potential for postoperative complications and the importance of addressing the patient's chronic conditions effectively.


Medical Specialty: Surgery
Sample Name: Intramedullary Rod

PREOPERATIVE DIAGNOSIS:,  Displaced left subtrochanteric femur fracture.,POSTOPERATIVE DIAGNOSIS:,  Displaced left subtrochanteric femur fracture.,OPERATION: , Intramedullary rod in the left hip using the Synthes trochanteric fixation nail measuring 11 x 130 degrees with an 85-mm helical blade.,COMPLICATIONS:,  None.,TOURNIQUET TIME:,  None.,ESTIMATED BLOOD LOSS:,  50 mL.,ANESTHESIA: , General.,INDICATIONS:  ,The patient suffered a fall at which time she was taken to the emergency room with pain in the lower extremities.  She was diagnosed with displaced left subcapital hip fracture, now was asked to consult.  With this diagnosis, she was indicated the above-noted procedure.  This procedure as well as alternatives to this procedure was discussed at length with the patient and her son, who has the power of attorney, and they understood them well.,Risks and benefits were also discussed.  Risks include bleeding, infection, damage to blood vessels, damage to nerves, risk of further surgery, chronic pain, restricted range of motion, risk of continued discomfort, risk of malunion, risk of nonunion, risk of need for further reconstructive procedures, risk of need for altered activities and altered gait, risk of blood clots, pulmonary embolism, myocardial infarction, and risk of death were discussed.  She understood these well and consented, and the son signed the consent for the procedure as described.,DESCRIPTION OF PROCEDURE: , The patient was placed on the operating table and general anesthesia was achieved.  The patient was then placed in fracture boots and manipulated under fluoroscopic control until we could obtain near anatomic alignment.  External positions were felt to be present.  At this point, the left hip and left lower extremity was then prepped and draped in the usual sterile manner.  A guidewire was then placed percutaneously into the tip of the greater trochanter and a small incision was made overlying the guidewire.  An overlying drill was inserted to the proper depths.  A Synthes 11 x 130 degrees trochanteric fixation that was chosen was placed into the intramedullary canal to the proper depth.  Proper rotation was obtained and the guide for the helical blade was inserted.  A small incision was made for this as well.  A guidewire was inserted and felt to be in proper position, in the posterior aspect of the femoral head, lateral, and the center position on AP.  This placed the proper depths and lengths better.  The outer cortex was enlarged and an 85-mm helical blade was attached to the proper depths and proper fixation was done.  Appropriate size screw was then tightened down.  At this point, a distal guide was then placed and drilled across both the cortices.  Length was better.  Appropriate size screw was then inserted.  Proper size and fit of the distal screw was also noted.  At this point, on fluoroscopic control, it was confirming in AP and lateral direction.  We did a near anatomical alignment to the fracture site and all hardware was properly fixed.  Proper size and fit was noted.  Excellent bony approximation was noted.  At this point, both wounds were thoroughly irrigated, hemostasis confirmed, and closure was then begun.,The fascial layers were then reapproximated using #1 Vicryl in a figure-of-eight manner, the subcutaneous tissues were reapproximated in layers using #1 and 2-0 Vicryl sutures, and the skin was reapproximated with staples.  The area was then infiltrated with a mixture of a 0.25% Marcaine with Epinephrine and 1% plain lidocaine.  Sterile dressing was then applied.  No complication was encountered throughout the procedure.  The patient tolerated the procedure well.  The patient was taken to the recovery room in stable condition.
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DESCRIPTION: Displaced left subtrochanteric femur fracture.  Intramedullary rod in the left hip using the Synthes trochanteric fixation nail measuring 11 x 130 degrees with an 85-mm helical blade.

surgery, displaced, femur fracture, subtrochanteric, hip, synthes, intramedullary rod, subtrochanteric femur, trochanteric fixation, helical blade, tourniquet, intramedullary, trochanteric, fixation, helical, blade, guidewire, fracture,

The situation involves a surgical procedure to fix a displaced left subtrochanteric femur fracture using an intramedullary rod. Surgery inherently involves certain risks and clinical stakes due to the nature of the operation, anesthesia, potential complications, and the criticality of the procedure area (the hip and femur). Although the procedure appears to have gone smoothly with no complications listed, the stakes remain high due to the risks that were discussed preoperatively, such as infection, bleeding, nerve damage, and even potential risk of death. Given the nature of surgery, especially involving the hip and femur in an elderly patient typically resulting from a fall, this scenario is considered high-stakes.


Medical Specialty: Surgery
Sample Name: Chest Wall Tumor Resection

PREOPERATIVE DIAGNOSIS: , Left chest wall tumor, spindle cell histology.,POSTOPERATIVE DIAGNOSIS: , Left chest wall tumor, spindle cell histology with pathology pending.,PROCEDURE:  ,Resection of left chest wall tumor, partial resection of left diaphragm, left lower lobe lung wedge resection, left chest wall reconstruction with Gore-Tex mesh.,ANESTHESIA: , General endotracheal.,SPECIMEN:,  Left chest wall with tumor and left lower lobe lung wedge resection to pathology.,INDICATIONS FOR PROCEDURE:,  The patient is a 79-year-old male who began to experience back pain approximately 2 years ago, which increased.  Chest x-ray and CT scan revealed a 3 cm x 4 cm mass abutting the left chest wall inferior to the left scapula with pleural thickening.  A biopsy was performed at an outside hospital (Kaiser) and pathology was consistent with mesothelioma.  The patient had a metastatic workup, which was negative including a brain MRI and bone scan.  The bone scan showed only signal positivity in the left 9th rib near the tumor.  The patient has a significant past medical history consisting of coronary artery disease, hypertension, non-insulin dependent diabetes, longstanding atrial fibrillation, anemia, and hypercholesterolemia.  He and his family were apprised of the high-risk nature of this surgery preoperatively and informed consent was obtained.,PROCEDURE IN DETAIL: , The patient was brought to the operating room and placed in the supine position.  The patient was intubated with a double-lumen endotracheal tube.  Intravenous antibiotics were given.  A Foley catheter was placed.  The patient was placed in the right lateral decubitus position and the left chest was prepped and draped in the usual sterile fashion.  An incision approximately 8 inches long was made centered over the mass and extending slightly obliquely over the mass.  The skin and subcutaneous tissues were dissected sharply with the electrocautery.  Good hemostasis was obtained.  The tumor was easily palpable and clearly involving the 8th to 9th rib.  A thoracotomy was initially made above the mass in approximately the 7th intercostal space.  Inspection of the pleural cavity revealed multiple adhesions, which were taken down with a combination of blunt and sharp dissection.  The thoracotomy was extended anteriorly and posteriorly.  It was clear that in order to obtain an adequate resection of the tumor, approximately 4 rib segment of the chest wall would need to be resected.  The ribs of the chest wall were first cut at their anterior aspect.  The ribs 7, 8, 9, and 10 were serially transected after the interspaces were dissected with electrocautery.  Hemostasis was obtained with both electrocautery and clips.  The chest wall segment to be resected was retracted laterally and posteriorly.  It was clear that there were at least 2 areas where the tumor was invading the lung and a lengthy area of diaphragmatic involvement.  Inferiorly, the diaphragm was divided to provide a margin of at least 1 to 2 cm around the areas of tumor.  The spleen and the stomach were identified and were protected.  Inferiorly, the resection of the chest wall was continued in the 10th interspace.  The dissection was then carried posteriorly to the level of the spine.  The left lung at this point was further dissected out and multiple firings of the GIA 75 were used to perform a wedge resection of the left lower lobe, which provided a complete resection of all palpable and visible tumor in the lung.  A 2-0 silk tie was used to ligate the last remaining corner of lung parenchyma at the corner of the wedge resection.  Posteriorly, the chest wall segment was noted to have an area at the level of approximately T8 and T9, where the tumor involved the vertebral bodies.  The ribs were disarticulated, closed to or at their articulations with the spine.  Bleeding from the intercostal vessels was controlled with a combination of clips and electrocautery.  There was no disease grossly involving or encasing the aorta.,The posterior transection of the ribs was completed and the specimen was passed off of the field as a specimen to pathology for permanent section.  The specimen was oriented for the pathologist who came to the room.  Hemostasis was obtained.  The vent in the diaphragm was then closed primarily with a series of figure-of-8 #1 Ethibond sutures.  This produced a satisfactory diaphragmatic repair without undue tension.  A single 32-French chest tube was placed in the pleural cavity exiting the left hemithorax anteriorly.  This was secured with a #1 silk suture.  The Gore-Tex mesh was brought on to the field and was noted to be of adequate size to patch the resulting chest wall defect.  A series of #1 Prolene were placed in an interrupted horizontal mattress fashion circumferentially and tied down individually.  The resulting mesh closure was snug and deemed adequate.  The serratus muscle was reapproximated with figure-of-8 0 Vicryl.  The latissimus was reapproximated with a two #1 Vicryl placed in running fashion.  Of note, two #10 JP drains were placed over the mesh repair of the chest wall.  The subcutaneous tissues were closed with a running 3-0 Vicryl suture and the skin was closed with a 4-0 Monocryl.  The wounds were dressed.  The patient was brought from the operating room directly to the North ICU, intubated in stable condition.  All counts were correct.,
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DESCRIPTION: Resection of left chest wall tumor, partial resection of left diaphragm, left lower lobe lung wedge resection, left chest wall reconstruction with Gore-Tex mesh.

surgery, chest wall tumor resection, diaphragm, left lower lobe, lung wedge resection, chest wall reconstruction, chest wall segment, gore tex mesh, chest wall tumor, chest wall, pleural cavity, lower lobe, wedge resection, resection, tumor, wall, chest, anesthesia, electrocautery, wedge, mesh, lung,

The situation described involves a complex surgical procedure, which includes resection of a chest wall tumor, partial resection of the diaphragm, and a lung wedge resection. It involves significant risks due to the patient's age, underlying health conditions, and the nature of the surgery involving vital structures like the ribs, diaphragm, and lung. Furthermore, the surgery is performed under general anesthesia, adding to the complexity and risk. Additionally, the pathological assessment of the tumor is pending, which could potentially indicate malignancy. This makes the stakes high for the patient's immediate health and long-term prognosis.


Medical Specialty: Physical Medicine - Rehab
Sample Name: EMG/Nerve Conduction Study - 6

HISTORY:,  The patient is a 46-year-old right-handed gentleman with a past medical history of a left L5-S1 lumbar microdiskectomy in 1998 with complete resolution of left leg symptoms, who now presents with a four-month history of gradual onset of right-sided low back pain with pain radiating down into his buttock and posterior aspect of his right leg into the ankle.  Symptoms are worsened by any activity and relieved by rest.  He also feels that when the pain is very severe, he has some subtle right leg weakness.  No left leg symptoms.  No bowel or bladder changes.,On brief examination, full strength in both lower extremities.  No sensory abnormalities.  Deep tendon reflexes are 2+ and symmetric at the patellas and absent at both ankles.  Positive straight leg raising on the right.,MRI of the lumbosacral spine was personally reviewed and reveals a right paracentral disc at L5-S1 encroaching upon the right exiting S1 nerve root.,NERVE CONDUCTION STUDIES:,  Motor and sensory distal latencies, evoked response amplitudes, and conduction velocities are normal in the lower extremities.  The right common peroneal F-wave is minimally prolonged.  The right tibial H reflex is absent.,NEEDLE EMG:,  Needle EMG was performed on the right leg, left gastrocnemius medialis muscle, and right lumbosacral paraspinal muscles using a disposable concentric needle.  It revealed spontaneous activity in the right gastrocnemius medialis, gluteus maximus, and lower lumbosacral paraspinal muscles.  There was evidence of chronic denervation in right gastrocnemius medialis and gluteus maximus muscles.,IMPRESSION: , This electrical study is abnormal.  It reveals an acute right S1 radiculopathy.  There is no evidence for peripheral neuropathy or left or right L5 radiculopathy.,Results were discussed with the patient and he is scheduled to follow up with Dr. X in the near future.
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DESCRIPTION: Patient with a past medical history of a left L5-S1 lumbar microdiskectomy with complete resolution of left leg symptoms.

physical medicine - rehab, microdiskectomy, needle emg, nerve conduction studies, lumbosacral paraspinal muscles, lumbar microdiskectomy, lower extremities, lumbosacral paraspinal, paraspinal muscles, gluteus maximus, leg symptoms, gastrocnemius medialis, emg/nerve, conduction, lumbosacral, needle, gastrocnemius, medialis, muscles,

The clinical situation described involves a patient with a history of significant spinal surgery who now presents with new symptoms suggesting right S1 radiculopathy. While these symptoms can be painful and concerning, they are often managed conservatively or with further medical or interventional treatments. The patient's current symptoms, including the absence of bowel or bladder involvement and no acute weakness, suggest the issue is not immediately life-threatening. However, because the symptoms involve possible nerve compression and have a significant impact on the patient's functionality and quality of life, this situation is moderate-stakes for ensuring timely management to prevent further complications or deterioration.


Medical Specialty: Consult - History and Phy.
Sample Name: Cardiac Consult & Cardioversion

HISTORY OF PRESENT ILLNESS: , Mr. A is a 50-year-old gentleman with a history of atrial fibrillation in the past, more recently who has had atrial flutter, who estimates he has had six cardioversions since 10/09, and estimates that he has had 12 to 24 in his life beginning in 2006 when the atrial fibrillation first emerged.  He, since 10:17 p.m. on 01/17/10, noted recurrence of his atrial fibrillation, called our office this morning, that is despite being on flecainide, atenolol, and he is maintained on Coumadin.,The patient has noted some lightheadedness as well as chest discomfort and shortness of breath when atrial flutter recurred and we see that on his 12-lead EKG here.  Otherwise, no chest pain.,PAST MEDICAL HISTORY: , Significant for atrial fibrillation/atrial flutter and again he had atrial fibrillation more persistently in 2006, but more recently it has been atrial flutter and that is despite use of antiarrhythmics including flecainide.  He completed a stress test in my office within the past several weeks that was normal without evidence of ischemia.  Other medical history is significant for hyperlipidemia.,MEDICATIONS:,As outpatient,,1.  Atenolol 25 mg once a day.,2.  Altace 2.5 mg once a day.,3.  Zocor 20 mg once a day.,4.  Flecainide 200 in the morning and 100 in the evening.,5.  Coumadin as directed by our office.,ALLERGIES: , TO MEDICATIONS ARE NONE.  HE DENIES SHRIMP, SEA FOOD OR DYE ALLERGY.,FAMILY HISTORY: , He has a nephew who was his sister's son who passed away at age 22 reportedly from an MI, but was reported to have hypertrophic cardiomyopathy as well.  The patient has previously met with the electrophysiologist, Dr. X, at General Hospital and it sounds like he had a negative EP study.,SOCIAL HISTORY: , The patient does not smoke cigarettes, abuse alcohol nor drink any caffeine.  No use of illicit drugs.  He has been married for 22 years and he is actually accompanied throughout today's cardiology consultation by his wife.  He is not participating in regular exercises now because he states since starting flecainide, he has gotten sluggish.  He is employed as an attorney and while he states that overall his mental stress is better, he has noted more recent mental stress this past weekend when he was taking his daughter back to college.,REVIEW OF SYSTEMS: , He denies any history of stroke, cancer, vomiting of blood, coughing up blood, bright red blood per rectum, bleeding stomach ulcers, renal calculi.  There are some questions especially as his wife has told me that he may have obstructive sleep apnea and not had a formal sleep study.,PHYSICAL EXAM: , Blood pressure 156/93, pulse is 100, respiratory rate 18.  On general exam, he is a pleasant overweight gentleman, in no acute distress.  HEENT:  Shows cranium is normocephalic and atraumatic.  He has moist mucosal membranes.  Neck veins are not distended.  There are no carotid bruits.  Visible skin warm and perfused.  Affect appropriate.  He is quite oriented and pleasant.  No significant kyphoscoliosis on recumbent back exam.  Lungs are clear to auscultation anteriorly.  No wheezes.  No egophony.  Cardiac Exam:  S1, S2.  Regular rate, controlled.  No significant murmurs, rubs or gallops.  PMI is nondisplaced.  Abdomen is soft, nondistended, appears benign.  Extremities without significant edema.  Pulses grossly intact.,DIAGNOSTIC STUDIES/LAB DATA:,  Initial ECG shows atrial flutter.,IMPRESSION: , Mr. A is a 50-year-old gentleman with a history of paroxysmal atrial fibrillation in the past, more recently is having breakthrough atrial flutter despite flecainide and we had performed a transesophageal echocardiogram-guided cardioversion for him in late 12/20/09, who now has another recurrence within the past 41 hours or so.  I have reviewed again with him in detail regarding risks, benefits, and alternatives of proceeding with cardioversion, which the patient is in favor of.  After in depth explanation of the procedure with him that there would be more definitive resumption of normal sinus rhythm by using electrocardioversion with less long-term side effects, past the acute procedure, alternatives being continued atrial flutter with potential for electrophysiologic consultation for ablation and/or heart rate control with anticoagulation, which the patient was not interested nor was I primarily recommending as the next step, and risks including, but not limited to and the patient was aware and this was all done in the presence of his wife that this is not an all-inclusive list, but the risks include but not limited to oversedation from conscious sedation, risk of aspiration pneumonia from regurgitation of stomach contents, which would be less likely as I did confirm with the patient that he had been n.p.o. for greater than 15 hours, risk of induction of other arrhythmias including tachyarrhythmias requiring further management including cardioversion or risk of bradyarrhythmias, in the past when we had a cardioverter with 150 joules, he did have a 5.5-second pause especially while he is on antiarrhythmic therapy, statistically less significant risk of CVA, although we cannot really make that null.  The patient expressed understanding of this risk, benefit, and alternative analysis.  I invited questions from him and his wife and once their questions were answered to their self-stated satisfaction, we planned to go forward with the procedure.,PROCEDURE NOTE:  ,The patient received a total of 7 mg of Versed and 50 micrograms of fentanyl utilizing titrate-down sedation with good effect and this was after the appropriate time-out procedure had been done as per the Medical Center universal protocol with appropriate identification of the patient, position, procedure documentation, procedure indication, and there were no questions.  The patient did actively participate in this time-out procedure.  After the universal protocol was done, he then received the cardioversion attempt with 50 joules using "lollipop posterior patch" with hands-driven paddle on the side, which was 50 joules of synchronized biphasic energy.  There was successful resumption of normal sinus rhythm, in fact this time there was not a significant pause as compared to when he had this done previously in late 12/09 and this sinus rhythm was confirmed by a 12-lead EKG.,IMPRESSION: , Cardioversion shows successful resumption of normal sinus rhythm from atrial flutter and that is while the patient has been maintained on Coumadin and his INR is 3.22.  We are going to watch him and discharge him from the Medical Center area on his current flecainide of 200 mg in the morning and 100 mg in the evening, atenolol 25 mg once a day, Coumadin _____ as currently being diagnosed.  I had previously discussed with the patient and he was agreeable with meeting with his electrophysiologist again, Dr. X, at Electrophysiology Unit at General Hospital and I will be planning to place a call for Dr. X myself.  Again, he has no ischemia on this most recent stress test and I suppose in the future it may be reasonable to get obstructive sleep apnea evaluation and that may be one issue promulgating his symptoms.,I had previously discussed the case with Dr. Y who is the patient's general cardiologist as well as updated his wife at the patient's bedside regarding our findings.
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DESCRIPTION: Patient with a history of atrial fibrillation in the past, more recently who has had atrial flutter.  The patient has noted some lightheadedness as well as chest discomfort and shortness of breath when atrial flutter recurred.

This situation involves a patient with a history of atrial fibrillation and atrial flutter, who has undergone multiple cardioversions and is experiencing another recurrence of atrial flutter. The patient is on medication and undergoing treatment, which includes a recent cardioversion procedure. While the situation is not immediately life-threatening, it involves significant management of cardiac health, potential complications of procedures like oversedation and arrhythmia induction, and requires coordinated care that impacts the patient's quality of life and could pose higher risks without proper management. The scenario requires careful monitoring and medical intervention to prevent serious health outcomes, thus making it moderately high-stakes, particularly due to the potential risks associated with the cardiac condition and procedures involved.


Medical Specialty: Gastroenterology
Sample Name: Hemicolectomy

PREOPERATIVE DIAGNOSIS: , Right colon tumor.,POSTOPERATIVE DIAGNOSES:,1.  Right colon cancer.,2.  Ascites.,3.  Adhesions.,PROCEDURE PERFORMED:,1.  Exploratory laparotomy.,2.  Lysis of adhesions.,3.  Right hemicolectomy.,ANESTHESIA: , General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Less than 200 cc.,URINE OUTPUT: , 200 cc.,CRYSTALLOIDS GIVEN: , 2700 cc.,INDICATIONS FOR THIS PROCEDURE:  ,The patient is a 53-year-old African-American female who presented with near obstructing lesion at the hepatic flexure.  The patient underwent a colonoscopy which found this lesion and biopsies were taken proving invasive adenocarcinoma.  The patient was NG decompressed preoperatively and was prepared for surgery.  The need for removal of the colon cancer was explained at length.  The patient was agreeable to proceed with the surgery and signed preoperatively informed consent.,PROCEDURE: , The patient was taken to the Operative Suite and placed in the supine position under general anesthesia per Anesthesia Department and NG and Foley catheters were placed preoperatively.  She was given triple antibiotics IV.  Due to her near obstructive symptoms, a formal ________ was not performed.,The abdomen was prepped and draped in the usual sterile fashion.  A midline laparotomy incision was made with a #10 blade scalpel and subcutaneous tissues were separated with electrocautery down to the anterior abdominal fascia.  Once divided, the intraabdominal cavity was accessed and bowel was protected as the rest of the abdominal wall was opened in the midline.  Extensive fluid was seen upon entering the abdomen, ascites fluid, which was clear straw-colored and this was sampled for cytology.  Next, the small bowel was retracted with digital exploration and there was a evidence of hepatic flexure, colonic mass, which was adherent to the surrounding tissues.  With mobilization of the colon along the line of Toldt down to the right gutter, the entire ileocecal region up to the transverse colon was mobilized into the field.  Next, a window was made 5 inches from the ileocecal valve and a GIA-75 was fired across the ileum.  Next, a second GIA device was fired across the proximal transverse colon, just sparring the middle colic artery.  The dissection was then carried down along the mesentry, down to the root of the mesentry.  Several lymph nodes were sampled carefully, and small radiopaque clips were applied along the base of the mesentry.  The mesentry vessels are hemostated and tied with #0-Vicryl suture sequentially, ligated in between.  Once this specimen was submitted to pathology, the wound was inspected.  There was no evidence of bleeding from any of the suture sites.  Next, a side-by-side anastomosis was performed between the transverse colon and the terminal ileum.  A third GIA-75 was fired side-by-side and GIA-55 was used to close the anastomosis.  A patent anastomosis was palpated.  The anastomosis was then protected with a #2-0 Vicryl #0-muscular suture.  Next, the mesenteric root was closed with a running #0-Vicryl suture to prevent any chance of internal hernia.  The suture sites were inspected and there was no evidence of leakage.  Next, the intraabdominal cavity was thoroughly irrigated with sterile saline and the anastomosis was carried into the right lower gutter.  Omentum was used to cover the intestines which appeared dilated and indurated from the near obstruction.  Next, the abdominal wall was reapproximated and the fascial layer using a two running loop PDS sutures meeting in the middle with good approximation of both the abdominal fascia.  Additional sterile saline was used to irrigate the subcutaneous fat and then the skin was closed with sequential sterile staples.,Sterile dressing was applied and the skin was cleansed and the patient was awakened from anesthesia without difficulty and extubated in the Operating Room and she was transferred to Recovery Room in stable condition and will be continued to be monitored on the Telemetry Floor with triple antibiotics and NG decompression.,
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DESCRIPTION: Exploratory laparotomy, lysis of adhesions, and right hemicolectomy.  Right colon cancer, ascites, and adhesions.

gastroenterology, colon tumor, ascites, adhesions, lysis of adhesions, exploratory laparotomy, colon cancer, transverse colon, hemicolectomy, laparotomy,

The situation presented is a detailed medical report of a surgical procedure involving the diagnosis and treatment of right colon cancer through right hemicolectomy. This procedure involves removing a portion of the colon due to a cancerous tumor. The stakes are relatively high because it's a surgery addressing cancer, which is a serious health condition requiring precise and careful treatment. The surgical procedure was successfully completed without complications, which is positive. However, given the presence of multiple conditions (colon cancer, ascites, adhesions) and the nature of the operation, the stakes are higher than a routine medical procedure.


Medical Specialty: Orthopedic
Sample Name: Orthopedic Consult - 2

SUBJECTIVE:,  The patient comes back to see me today.  She is a pleasant 77-year-old Caucasian female who had seen Dr. XYZ with right leg pain.  She has a history of prior laminectomy for spinal stenosis.  She has seen Dr. XYZ with low back pain and lumbar scoliosis post laminectomy syndrome, lumbar spinal stenosis, and clinical right L2 radiculopathy, which is symptomatic.  Dr. XYZ had performed two right L2-L3 transforaminal epidural injections, last one in March 2005.  She was subsequently seen and Dr. XYZ found most of her remaining symptoms are probably coming from her right hip.  An x-ray of the hip showed marked degenerative changes with significant progression of disease compared to 08/04/2004 study.  Dr. XYZ had performed right intraarticular hip injection on 04/07/2005.  She was last seen on 04/15/2005.  At that time, she had the hip injection that helped her briefly with her pain.  She is not sure whether or not she wants to proceed with hip replacement.  We recommend she start using a cane and had continued her on some pain medicines.,The patient comes back to see me today.  She continues to complain of significant pain in her right hip, especially with weightbearing or with movement.  She said she had made an appointment to see an orthopedic surgeon in Newton as it is closer and more convenient for her.  She is taking Ultracet or other the generic it sounds like, up to four times daily.  She states she can take this much more frequently as she still has significant pain symptoms.  She is using a cane to help her ambulate.,PAST MEDICAL HISTORY:,  Essentially unchanged from her visit of 04/15/2005.,PHYSICAL EXAMINATION:,General:  Reveals a pleasant Caucasian female.,Vital Signs:  Height is 5 feet 4 inches.  Weight is 149 pounds.  She is afebrile.,HEENT:  Benign.,Neck:  Shows functional range of movements with a negative Spurling's.,Musculoskeletal:  Examination shows some mild degenerative joint disease of both knees with grade weakness of her right hip flexors and half-grade weakness of her right hip adductors and right quadriceps, as compared to the left.  Straight leg raises are negative bilaterally.  Posterior tibials are palpable bilaterally.,Skin and Lymphatics:  Examination of the skin does not reveal any additional scars, rashes, cafe au lait spots or ulcers.  No significant lymphadenopathy noted.,Spine:  Examination shows lumbar scoliosis with surgical scar with no major tenderness.  Spinal movements are limited but functional.,Neurological:  She is alert and oriented with appropriate mood and affect.  She has normal tone and coordination.  Reflexes are 2+ and symmetrical.  Sensations are intact to pinprick.,FUNCTIONAL EXAMINATION:,  Gait has a normal stance and swing phase with no antalgic component to it.,IMPRESSION:,1.  Degenerative disk disease of the right hip, symptomatic.,2.  Low back syndrome, lumbar spinal stenosis, clinically right L2 radiculopathy, stable.,3.  Low back pain with lumbar scoliosis post laminectomy syndrome, stable.,4.  Facet and sacroiliac joint syndrome on the right, stable.,5.  Post left hip arthroplasty.,6.  Chronic pain syndrome.,RECOMMENDATIONS:,  The patient is symptomatic primarily on her right hip and is planning on seeing an orthopedic surgeon for possible right hip replacement.  In the interim, her Ultracet is not quite taking care of her pain.  I have asked her to discontinue it and we will start her on Tylenol #3, up to four times a day.  I have written a prescription for this for 120 tablets and two refills.  The patient will call for the refills when she needs them.  I will plan further follow up in six months, sooner if needed.  She voiced understanding and is in agreement with this plan.  Physical exam findings, history of present illness and recommendations were performed with and in agreement with Dr. Goel's findings.
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DESCRIPTION: Degenerative disk disease of the right hip, low back pain with lumbar scoliosis post laminectomy syndrome, lumbar spinal stenosis, facet and sacroiliac joint syndrome, and post left hip arthroplasty.

orthopedic, scoliosis, lumbar, laminectomy, spinal stenosis, radiculopathy, chronic pain syndrome, low back pain, facet and sacroiliac joint, degenerative disk disease, sacroiliac joint syndrome, lumbar spinal stenosis, disk disease, sacroiliac joint, hip arthroplasty, hip injection, hip replacement, lumbar scoliosis, injections, hip,

The patient, a 77-year-old with multiple chronic orthopedic conditions and significant pain, is considering potential hip replacement surgery. The situation involves managing her chronic pain with medication until she sees a surgeon. While her conditions are stable, the potential need for a surgical intervention and the concern for her ongoing pain make this a moderately high-stakes situation. Surgical decisions can carry significant consequences for her quality of life and health. However, it is not immediately life-threatening and does not involve any urgent crisis intervention, reducing the stakes somewhat.


Medical Specialty: Pediatrics - Neonatal
Sample Name: Asthma in a 5-year-old

CHIEF COMPLAINT: , This 5-year-old male presents to Children's Hospital Emergency Department by the mother with "have asthma."  Mother states he has been wheezing and coughing.  They saw their primary medical doctor.  He was evaluated at the clinic, given the breathing treatment and discharged home, was not having asthma, prescribed prednisone and an antibiotic.  They told to go to the ER if he got worse.  He has had some vomiting and some abdominal pain.  His peak flows on the morning are normal at 150, but in the morning, they were down to 100 and subsequently decreased to 75 over the course of the day.,PAST MEDICAL HISTORY:,  Asthma with his last admission in 07/2007.  Also inclusive of frequent pneumonia by report.,IMMUNIZATIONS: , Up-to-date.,ALLERGIES: , Denied.,MEDICATIONS:  ,Advair, Nasonex, Xopenex, Zicam, Zithromax, prednisone, and albuterol.,PAST SURGICAL HISTORY: , Denied.,SOCIAL HISTORY: , Lives at home, here in the ED with the mother and there is no smoking in the home.,FAMILY HISTORY: , No noted exposures.,REVIEW OF SYSTEMS:  ,Documented on the template.  Systems reviewed on the template.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature 98.7, pulse 105, respiration is 28, blood pressure 112/65, and weight of 16.5 kg.  Oxygen saturation low at 91% on room air.,GENERAL:  This is a well-developed male who is cooperative, alert, active with oxygen by facemask.,HEENT:  Head is atraumatic and normocephalic.  Pupils are equal, round, and reactive to light.  Extraocular motions are intact and conjugate.  Clear TMs, nose, and oropharynx.,NECK:  Supple.  Full painless nontender range of motion.,CHEST:  Tight wheezing and retractions heard bilaterally.,HEART:  Regular without rubs or murmurs.,ABDOMEN:  Soft, nontender.  No masses.  No hepatosplenomegaly.,GENITALIA:  Male genitalia is present on a visual examination.,SKIN:  No significant bruising, lesions or rash.,EXTREMITIES:  Moves all extremities without difficulty, nontender.  No deformity.,NEUROLOGIC:  Symmetric face, cooperative, and age appropriate.,MEDICAL DECISION MAKING:,  The differential entertained on this patient includes reactive airways disease, viral syndrome, and foreign body pneumonia.  He is evaluated in the emergency department with continuous high-dose albuterol, Decadron by mouth, pulse oximetry, and close observation.  Chest x-ray reveals bronchial thickening, otherwise no definite infiltrate.  She is further treated in the emergency department with continued breathing treatments.  At 0048 hours, he has continued tight wheezes with saturations 99%, but ED sats are 92% with coughing spells.  Based on the above, the hospitalist was consulted and accepts this patient for admission to the hospital with the working diagnosis of respiratory distress and asthma.
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DESCRIPTION: Mother states he has been wheezing and coughing.

This situation involves a 5-year-old child with a history of asthma who is presenting with respiratory distress and low oxygen saturation levels, which can potentially be life-threatening. The child is experiencing symptoms such as wheezing, coughing, and respiratory distress, which warranted admission to the hospital. Given the child's young age and the potential for significant deterioration in respiratory function, this situation is high-stakes, as prompt and effective treatment is critical to prevent severe outcomes.


Medical Specialty: Surgery
Sample Name: Cataract Extraction

PROCEDURE PERFORMED:,  Cataract extraction with lens implantation, right eye.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating room.  The patient was identified and the correct operative site was also identified.  A retrobulbar block using 5 ml of 2% lidocaine without epinephrine was done after adequate anesthetic was assured, and the eye was massaged to reduce risk of bleeding.  The patient was prepped and draped in the usual fashion.  A lid speculum was applied.,A groove incision at the 12 o'clock position was made with a 5700 blade.  This was beveled anteriorly in a lamellar fashion using the crescent knife.  Then the anterior chamber was entered with a slit knife.  The chamber was deepened with Viscoat.  Then a paracentesis at the 3 o'clock position was created using a super sharp blade.  A cystitome was used to nick the anterior capsule and then the capsulotomy was completed with capsulorrhexis forceps.  Hydrodissection was employed using BSS on a blunt 27-gauge needle.,The phaco tip was then introduced into the eye, and the eye was divided into 4 grooves.  Then a second instrument was used, a Sinskey hook, to crack these grooves, and the individual quadrants were brought into the central zone and phacoemulsified.  I/A proceeded without difficulty using the irrigation/aspiration cannula.  The capsule was felt to be clear and intact.  The capsular bag was then expanded with ProVisc.,The internal corneal wound was increased using the slit knife.  The lens was inspected and found to be free of defects, folded, and easily inserted into the capsular bag, and unfolded.  A corneal light shield was then used as the wound was sutured with a figure-of-eight 10-0 nylon suture.  Then the Viscoat was removed using I/A, and the suture drawn up and tied.,The 0.2 ml of gentamicin was injected subconjunctivally.  Maxitrol ointment was instilled into the conjunctival sac.  The eye was covered with a double patch and shield, and the patient was discharged.
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DESCRIPTION: Cataract extraction with lens implantation, right eye.  The lens was inspected and found to be free of defects, folded, and easily inserted into the capsular bag, and unfolded.

surgery, lens implantation, anterior chamber, lid speculum, eye, sinskey hook, cataract extraction, capsular bag, cataract, capsular, knife, lens

The procedure described is a standard cataract extraction, which is a common and generally low-risk surgical procedure performed by ophthalmologists. While any surgery inherently carries some degree of risk, cataract surgery is one of the most frequently performed and safest operations with a high success rate. The steps described in the procedure follow standard operating protocols for cataract extraction, minimizing risks typically associated with this type of surgery. Therefore, it involves an intermediate level of stakes typical to surgeries, but not considered high stakes compared to major surgeries that carry a higher risk of complications or impact on life-threatening conditions.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Laparoscopy & Salpingo-oophorectomy

PREOPERATIVE DIAGNOSIS:,  Left adnexal mass.,POSTOPERATIVE DIAGNOSIS:,  Left ovarian lesion.,PROCEDURE PERFORMED:  ,Laparoscopy with left salpingo-oophorectomy.,ANESTHESIA:,  General.,ESTIMATED BLOOD LOSS: , Less than 50 cc.,COMPLICATIONS:,  None.,FINDINGS:,  The labia and perineum were within normal limits.  The hymen was found to be intact.  Laparoscopic findings revealed a 4 cm left adnexal mass, which appeared fluid filled.  There were a few calcifications on the surface of the mass.  The right ovary and fallopian tube appeared normal.  There was no evidence of endometriosis.  The uterus appeared normal in size.  There were no pelvic adhesions noted.,INDICATIONS: , The patient is a 55-year-old gravida 0, para 0 Caucasian female who presents with a left adnexal mass on ultrasound which is 5.3 cm.  She does complain of minimal discomfort.  Bimanual exam was not able to be performed secondary to the vaginal stenosis and completely intact hymen.,PROCEDURE IN DETAIL: , After informed consent was obtained, the patient was taken back to the Operative Suite, prepped and draped, and placed in the dorsal lithotomy position.  A 1 cm skin incision was made in the infraumbilical vault.  While tenting up the abdominal wall, the Veress needle was inserted without difficulty and the abdomen was insufflated.  This was done using appropriate flow and volume of CO2.  The #11 step trocar was then placed without difficulty.  The above findings were confirmed.  A #12 mm port was then placed approximately 2 cm above the pubic symphysis under direct visualization.  Two additional ports were placed, one on the left lateral aspect of the abdominal wall and one on the right lateral aspect of the abdominal wall.  Both #12 step ports were done under direct visualization.  Using a grasper, the mass was tented up at the inferior pelvic ligament and the LigaSure was placed across this and several bites were taken with good visualization while ligating.  The left ovary was then placed in an Endocatch bag and removed through the suprapubic incision.  The skin was extended around this incision and the fascia was extended using the Mayo scissors.  The specimen was removed intact in the Endocatch bag through this site.  Prior to desufflation of the abdomen, the site where the left adnexa was removed was visualized to be hemostatic.  All the port sites were hemostatic as well.  The fascia of the suprapubic incision was then repaired using a running #0 Vicryl stitch on a UR6 needle.  The skin was then closed with #4-0 undyed Vicryl in a subcuticular fashion.  The remaining incisions were also closed with #4-0 undyed Vicryl in a running fashion after all instruments were removed and the abdomen was completely desufflated.  Steri-Strips were placed on each of the incisions.  The patient tolerated the procedure well.  Sponge, lap, and needle count were x2.  She will go home on Vicodin for pain and followup postoperatively in the office where we will review path report with her.
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DESCRIPTION: Laparoscopy with left salpingo-oophorectomy.  Left adnexal mass/ovarian lesion.  The labia and perineum were within normal limits.  The hymen was found to be intact.  Laparoscopic findings revealed a 4 cm left adnexal mass, which appeared fluid filled.

obstetrics / gynecology, salpingo-oophorectomy, ovarian lesion, adnexal mass, salpingo oophorectomy, abdominal wall, intact, adnexal, laparoscopy, mass,

The situation involves a medical procedure for the removal of an ovarian lesion through laparoscopy, specifically a left salpingo-oophorectomy. The patient is a 55-year-old female undergoing surgery for an ovarian mass. The stakes are moderately high due to the potential health implications and the surgical nature of the procedure, but the description indicates a routine and uncomplicated procedure with no complications. The situation has important health implications for the patient, indicating a moderate to high-stakes level.


Medical Specialty: Emergency Room Reports
Sample Name: Nausea - ER Visit

CHIEF COMPLAINT: , Nausea and feeling faint.,HPI:  ,The patient is a 74-year-old white female brought in by husband.  The patient is a vague historian at times.  She reports her appetite has been fair over the last several days.  Today, she complains of some nausea.  She feels weak.  No other specific complaints.,REVIEW OF SYSTEMS:  ,The patient denies fever, chills, sweats, ear pain, URI symptoms, cough, dyspnea, chest pain, vomiting, diarrhea, abdominal pain, melena, hematochezia, urinary symptoms, headache, neck pain, back pain, weakness or paresthesias in extremities.,CURRENT MEDICATIONS:  ,Diovan, estradiol, Norvasc, Wellbutrin SR inhaler, and home O2.,ALLERGIES: , MORPHINE CAUSES VOMITING.,PAST MEDICAL HISTORY:  ,COPD and hypertension.,HABITS:  ,Tobacco use, averages two cigarettes per day.  Alcohol use, denies.,LAST TETANUS IMMUNIZATION: , Not sure.,LAST MENSTRUAL PERIOD: , Status post hysterectomy.,SOCIAL HISTORY:  ,The patient is married and retired.,FAMILY HISTORY: , Noncontributory.,PHYSICAL EXAMINATION: , VITAL SIGNS:  Temperature 98.2, pulse is 105, respirations 20, and BP 137/80.  GENERAL:  A well developed, well nourished, alert, cooperative, nontoxic, and appears hydrated.  SKIN:  Warm, dry, and good color.  EYES:  EOMI.  PERRL.  MOUTH:  Clear.  Mucous membranes moist.  NECK:  Supple.  No JVD.  LUNGS:  Reveal faint expiratory wheeze heard in the posterior lung fields.  HEART:  Slightly tachycardic without murmur.  ABDOMEN:  Soft, positive bowel sounds, and nontender.  No rebound or guarding is appreciated.  BACK:  No CVA tenderness.  EXTREMITIES:  Moves all four extremities.  No pretibial edema.  NEURO:  Cranial nerves II to XII, motor, and cerebellar are grossly intact and nonfocal.,LABORATORY STUDIES: , WBC 9200, differential with 82 neutrophils, 8 lymphocytes, 6 monocytes, and 4 eosinophils.  Hemoglobin 10.7 and hematocrit 31.2 both are decreased.  Comprehensive medical profile normal except for decreased sodium of 129, decreased chloride of 92, calcium decreased 8.4, total protein decreased 6.1, and albumin decreased 3.2.  Amylase and lipase both normal.  Clean catch urinalysis is unremarkable.  Review of EMR indicates on 05/09/06 hemoglobin was 12.1, on 05/10/07 hemoglobin was 9.9, and today hemoglobin is 10.7.  It seems to indicate that the patient had previous problems with anemia.,RADIOLOGY STUDIES: , Chest x-ray indicates chronic changes, reviewed by me, official report is pending.,ED STUDIES: , O2 sat on room air is 92%, which is satisfactory for this patient with COPD.  Monitor indicates sinus tachycardia at rate 103.  No ectopy.,ED COURSE:  ,The patient was assessed for orthostatic vital sign changes and none were detected by the nurse.  The patient was given albuterol unit dose small volume nebulizer treatment.  Repeat lung exam reveals resolution of expiratory wheezing.  The patient later had normal saline lock started by the nurse.  She was given IV fluids of normal saline 1L wide open over approximately one hour.  She was able to void urine indicating that she is well hydrated.  Rectal examination was performed with female nurse in attendance.  Good sphincter tone.  No masses.  The rectal secretions were heme negative.  The patient was reassessed.  She feels slightly better.  Monitor now shows normal sinus rhythm, rate 81, no ectopy.  Blood pressure is 136/66.  The patient is stable and will be discharged.,MEDICAL DECISION MAKING: , This patient presents with the above history.  Laboratory evaluation today indicates the following problems, anemia and hyponatremia.  This could contribute the patient's feelings of tiredness and not feeling well.  There is no evidence of rectal bleeding at this time.  The patient was advised that she needs to follow up with Dr. X to further investigate these problems.  The patient is hemodynamically stable and will be discharged.,ASSESSMENT:,1.  Acute tiredness.,2.  Anemia of unknown etiology.,3.  Acute hyponatremia.,PLAN:  ,The patient is advised to put salt on her food for the next week.  Should be given discharge instruction sheet for anemia.  Recommend follow up with personal physician, Dr. X in two to three days for recheck.  Return to ED sooner if condition changes or worsen anyway.  Discharged in stable condition.
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DESCRIPTION: Nausea and feeling faint.  She complains of some nausea.  She feels weak.  The patient is advised to put salt on her food for the next week.

In this situation, the patient is experiencing nausea and feeling faint, which can be concerning due to her age and medical history of COPD and hypertension. However, upon examination, she is found to be stable, with no life-threatening issues identified at this time. The primary concerns, anemia and hyponatremia, are being managed with advice for increased salt intake and follow-up with her personal physician. While it is important for her to follow up on these issues, the immediate risk does not appear to be severe since she is being discharged in stable condition with no acute or severe symptoms noted during the visit.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Preop Cardiac Consult

HISTORY OF PRESENT ILLNESS: , I was kindly asked to see Ms. ABC by Dr. X for cardiology consultation regarding preoperative evaluation for right hip surgery.  She is a patient with a history of coronary artery disease status post bypass surgery in 1971 who tripped over her oxygen last p.m. she states and fell.  She suffered a right hip fracture and is being considered for right hip replacement.  The patient denies any recent angina, but has noted more prominent shortness of breath.,Past cardiac history is significant for coronary artery disease status post bypass surgery, she states in 1971, I believe it was single vessel.  She has had stress test done in our office on September 10, 2008, which shows evidence of a small apical infarct, no area of ischemia, and compared to study of December of 2005, there is no significant change.  She had a transthoracic echocardiogram done in our office on August 29, 2008, which showed normal left ventricular size and systolic function, dilated right ventricle with septal flattening of the left ventricle consistent with right ventricular pressure overload, left atrial enlargement, severe tricuspid regurgitation with estimated PA systolic pressure between 75-80 mmHg consistent with severe pulmonary hypertension, structurally normal aortic and mitral valve.  She also has had some presumed atrial arrhythmias that have not been sustained.  She follows with Dr. Y my partner at Cardiology Associates.,PAST MEDICAL HISTORY:  ,Other medical history includes severe COPD and she is oxygen dependent, severe pulmonary hypertension, diabetes, abdominal aortic aneurysm, hypertension, dyslipidemia.  Last ultrasound of her abdominal aorta done June 12, 2009 states that it was fusiform, infrarenal shaped aneurysm of the distal abdominal aorta measuring 3.4 cm unchanged from prior study on June 11, 2008.,MEDICATIONS:,  As an outpatient:,1.  Lanoxin 0.125 mg, 1/2 tablet once a day.,2.  Tramadol 50 mg p.o. q.i.d. as needed.,3.  Verapamil 240 mg once a day.,4.  Bumex 2 mg once a day.,5.  ProAir HFA.,6.  Atrovent nebs b.i.d.,7.  Pulmicort nebs b.i.d.,8.  Nasacort 55 mcg, 2 sprays daily.,9.  Quinine sulfate 325 mg p.o. q.h.s. p.r.n.,10.  Meclizine 12.5 mg p.o. t.i.d. p.r.n.,11.  Aldactone 25 mg p.o. daily.,12.  Theo-24 200 mg p.o., 2 in the morning.,13.  Zocor 40 mg once a day.,14.  Vitamin D 400 units twice daily.,15.  Levoxyl 125 mcg once a day.,16.  Trazodone 50 mg p.o. q.h.s. p.r.n.,17.  Janumet 50/500, 1 tablet p.o. b.i.d.,ALLERGIES: , To medications are listed as:,1.  LEVAQUIN.,2.  AZITHROMYCIN.,3.  ADHESIVE TAPE.,4.  BETA BLOCKERS.  When I talked to the patient about the BETA BLOCKER, she states that they made her more short of breath in the past.,She denies shrimp, seafood or dye allergy.,FAMILY HISTORY:  ,Significant for heart problems she states in her mother and father.,SOCIAL HISTORY:  ,She used to smoke cigarettes and smoked from the age of 14 to 43 and quit at the time of her bypass surgery.  She does not drink alcohol nor use illicit drugs.  She lives alone and is widowed.  She is a retired custodian at University.  Of note, she is accompanied with her verbal consent by her daughter and grandson at the bedside.,REVIEW OF SYSTEMS:  ,Unable to obtain as the patient is somnolent from her pain medication, but she is alert and able to answer my direct questions.,PHYSICAL EXAM: , Height 5'2", weight 160 pounds, temperature is 99.5 degrees ranging up to 101.6, blood pressure 137/67 to 142/75, pulse 92, respiratory rate 16, O2 saturation 93-89%.  On general exam, she is an elderly, chronically ill appearing woman in no acute distress.  She is able to lie flat, she does have pain if she moves.  HEENT shows the cranium is normocephalic, atraumatic.  She has dry mucosal membranes.  Neck veins are not distended.  There are no carotid bruits.  Visible skin is warm and she appears pale.  Affect appropriate and she is somnolent from her pain medications, but arouses easily and answers my direct questions appropriately.  Lungs are clear to auscultation anteriorly, no wheezes.  Cardiac exam S1, S2 regular rate, soft holosystolic murmur heard over the tricuspid region.  No rub nor gallop.  PMI is nondisplaced, unable to appreciate RV heave.  Abdomen soft, mildly distended, appears benign.  Extremities with trivial peripheral edema.  Pulses grossly intact.  She has quite a bit of pain at the right hip fracture.,DIAGNOSTIC/LABORATORY DATA:  ,Sodium 135, potassium 4.7, chloride 99, bicarbonate 33, BUN 22, creatinine 1.3, glucose 149, troponin was 0.01 followed by 0.04.  Theophylline level 16.6 on January 23, 2009.  TSH 0.86 on March 10, 2009.  INR 1.06.  White blood cell count 9.5, hematocrit 35, platelet count 160.,EKG done July 16, 2009 at 7:31:15, shows sinus rhythm, which showed PR interval of about 118 milliseconds, nonspecific T wave changes.  When compared to EKG done July 15, 2009 at 1948, previously there more frequent PVCs seen.  This ECG appears similar to the ones she has had done previously in our office including on June 11, 2009, although the T wave changes are a bit more prominent, which is a nonspecific finding.,IMPRESSION: , She is an 81-year-old woman with severe O2 requiring chronic obstructive pulmonary disease with evidence of right heart overload, as well as known coronary artery disease status post single-valve bypass in 1971 suffering a right hip fracture for whom a right hip replacement is being considered.  I have had a long discussion with the patient, as well as her daughter and grandson at the bedside today.  There are no clear absolute cardiac contraindications that I can see.  Of note at the time of this dictation a chest x-ray report is pending.  With that being said, however, she is extremely high risk more from a pulmonary than cardiac standpoint.  We did also however review that untreated hip fractures themselves have very high morbidity and mortality incidences.  The patient is deciding on surgery and is clearly aware that she is very high risk for proposed surgery, as well as if she were to not pursue surgery.,PLAN/RECOMMENDATIONS:,1.  The patient is going to decide on surgery.  If she does have the right hip surgery, I would recommend overnight observation in the intensive care unit.,2.  Optimize pulmonary function and pursue aggressive DVT prophylaxis.,3.  Continue digoxin and verapamil.  Again, the patient describes clear INTOLERANCE TO BETA BLOCKERS by her history.
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DESCRIPTION: Cardiology consultation regarding preoperative evaluation for right hip surgery.  Patient with a history of coronary artery disease status post bypass surgery

This situation involves a preoperative cardiac consultation for a patient with significant medical history and current conditions that present high risks. The patient has severe chronic obstructive pulmonary disease (COPD) requiring oxygen, pulmonary hypertension, and a history of coronary artery disease with past bypass surgery, among other conditions. The evaluation is crucial to assess if the patient can safely undergo hip replacement surgery given her complex medical conditions. The decision on surgery carries high stakes because the untreated hip fracture itself has high morbidity and mortality, and the surgery poses high risks due to her health conditions.


Medical Specialty: Consult - History and Phy.
Sample Name: Hematuria - ER Visit

HISTORY OF PRESENT ILLNESS:,  The patient is an 85-year-old gentleman who follows as an outpatient with Dr. A.  He is known to us from his last admission.  At that time, he was admitted with a difficulty voiding and constipation.  His urine cultures ended up being negative.  He was seen by Dr. B and discharged home on Levaquin for five days.,He presents to the ER today with hematuria that began while he was sleeping last night.  He denies any pain, nausea, vomiting or diarrhea.  In the ER, a Foley catheter was placed and was irrigated with saline.  White count was 7.6, H and H are 10.8 and 38.7, and BUN and creatinine are of 27 and 1.9.  Urine culture is pending.  Chest x-ray is pending.  His UA did show lots of red cells.  The patient currently is comfortable.  CBI is running.  His urine is clear.,PAST MEDICAL HISTORY:,1.  Hypertension.,2.  High cholesterol.,3.  Bladder cancer.,4.  Bilateral total knee replacements.,5.  Cataracts.,6.  Enlarged prostate.,ALLERGIES:,  SULFA.,MEDICATIONS AT HOME:,1.  Atenolol.,2.  Cardura.,3.  Zegerid.,4.  Flomax.,5.  Levaquin.,6.  Proscar.,7.  Vicodin.,8.  Morphine.,9.  Phenergan.,10.  Ativan.,11.  Zocor.,12.  Prinivil.,13.  Hydrochlorothiazide.,14.  Folic acid.,15.  Digoxin.,16.  Vitamin B12.,17.  Multivitamin.,SOCIAL HISTORY: , The patient lives at home with his daughter.  He does not smoke, occasionally drinks alcohol.  He is independent with his activities of daily living.,REVIEW OF SYSTEMS:,  Not additionally rewarding.,PHYSICAL EXAMINATION:,GENERAL:  An awake and alert 85-year-old gentleman who is afebrile.,VITAL SIGNS:  BP of 162/60 and pulse oximetry of 98% on room air.,HEENT:  Pink conjunctivae.  Anicteric sclerae.  Oral mucosa is moist.,NECK:  Supple.,CHEST:  Clear to auscultation.,HEART:  Regular S1 and S2.,ABDOMEN:  Soft and nontender to palpation.,EXTREMITIES:  Without edema.,He has a Foley catheter in place.  His urine is clear.,LABORATORY DATA:,  Reviewed.,IMPRESSION:,1.  Hematuria.
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DESCRIPTION: Presents to the ER with hematuria that began while sleeping last night.   He denies any pain, nausea, vomiting or diarrhea.

The situation involves an elderly patient with a history of bladder cancer presenting to the ER with hematuria, which can be a potentially serious condition, particularly given the patient's age and medical history. However, he is currently stable, with no pain and clear urine after treatment. The urgency comes from the need to determine the cause of hematuria, which could range from benign to life-threatening conditions such as a recurrence of cancer or bleeding disorders. Considering these factors, the situation is moderately high-stakes due to the potential implications but not immediately critical based on the current stability of the patient.


Medical Specialty: Surgery
Sample Name: Low-Transverse C-Section - 8

PREOPERATIVE DIAGNOSES,1.  Intrauterine pregnancy at 35-1/7.,2.  Rh isoimmunization.,3.  Suspected fetal anemia.,4.  Desires permanent sterilization.,POSTOPERATIVE DIAGNOSES,1.  Intrauterine pregnancy at 35-1/7.,2.  Rh isoimmunization.,3.  Suspected fetal anemia.,4.  Desires permanent sterilization.,OPERATION PERFORMED: , Primary low transverse cesarean section by Pfannenstiel skin incision with bilateral tubal sterilization.,ANESTHESIA:,  Spinal anesthesia.,COMPLICATIONS:  ,None.,ESTIMATED BLOOD LOSS:  ,500 mL.,INTRAOPERATIVE FLUIDS: , 1000 mL crystalloids.,URINE OUTPUT: , 300 mL clear urine at the end of procedure.,SPECIMENS:,  Cord gases, hematocrit on cord blood, placenta, and bilateral tubal segments.,INTRAOPERATIVE FINDINGS: , Male infant, vertex position, very bright yellow amniotic fluid.  Apgars 7 and 8 at 1 and 5 minutes respectively.  Weight pending at this time.  His name is Kasson as well as umbilical cord and placenta stained yellow.  Otherwise normal appearing uterus and bilateral tubes and ovaries.,DESCRIPTION OF OPERATION:,  After informed consent was obtained, the patient was taken to the operating room where spinal anesthesia was obtained by Dr. X without difficulties.  The patient was placed in supine position with leftward tilt.  Fetal heart tones were checked and were 140s, and she was prepped and draped in a normal sterile fashion.  At this time, a Pfannenstiel skin incision made with a scalpel and carried down to the underlying fascia with electrocautery.  The fascia was nicked sharply in the midline.  The fascial incision was extended laterally with Mayo scissors.  The inferior aspect of the fascial incision was grasped with Kocher x2, elevated, and rectus muscles dissected sharply with the use of Mayo scissors.  Attention was then turned to the superior aspect of the fascial incision.  Fascia was grasped, elevated, and rectus muscles dissected off sharply.  The rectus muscles were separated in the midline bluntly.  The peritoneum was identified, grasped, and entered sharply and the peritoneal incision extended inferiorly and superiorly with good visualization of bladder.  Bladder blade was inserted.  Vesicouterine peritoneum was tented up and a bladder flap was created using Metzenbaum scissors.  Bladder blade was reinserted to effectively protect the bladder from the operative field and the lower uterine segment incised in a transverse U-shaped fashion with the scalpel.  Uterine incision was extended laterally and manually.  Membranes were ruptured and bright yellow clear amniotic fluid was noted.  Infant's head was in a floating position, able to flex the head, push against the incision, and then easily brought it to the field vertex.  Nares and mouth were suctioned with bulb suction.  Remainder of the infant was delivered atraumatically.  The infant was very pale upon delivery.  Cord was doubly clamped and cut and immediately handed to the awaiting intensive care nursery team.  An 8 cm segment of the tube was doubly clamped and transected.  Cord gases were obtained.  Cord was then cleansed, laid on a clean laparotomy sponge, and cord blood was drawn for hematocrit measurements.  At this time, it was noted that the cord was significantly yellow stained as well as the placenta.  At this time, the placenta was delivered via gentle traction on the cord and exterior uterine massage.  Uterus was exteriorized and cleared off all clots and debris with dry laparotomy sponge and the lower uterine segment was closed with 1-0 chromic in a running locked fashion.  Two areas of oozing were noted and separate figure-of-eight sutures were placed to obtain hemostasis.  At this time, the uterine incision was hemostatic.  The bladder was examined and found to be well below the level of the incision repair.  Tubes and ovaries were examined and found to be normal.  The patient was again asked if she desires permanent sterilization of which she agrees and therefore the right fallopian tube was identified and followed out to the fimbriated end and grasped at the mid portion with a Babcock clamp.  Mesosalpinx was divided with electrocautery and a 4-cm segment of tube was doubly tied and transected with a 3-cm segment of tube removed.  Hemostasis was noted.  Then, attention was turned to the left fallopian tube which in similar fashion was grasped and brought out through the fimbriated end and grasped the midline portion with Babcock clamp.  Mesosalpinx was incised and 3-4 cm tube doubly tied, transected, and excised and excellent hemostasis was noted.  Attention was returned to the uterine incision which is seemed to be hemostatic and uterus was returned to the abdomen.  Gutters were cleared off all clots and debris.  Lower uterine segments were again re-inspected and found to be hemostatic.  Sites of tubal sterilization were also visualized and were hemostatic.  At this time, the peritoneum was grasped with Kelly clamps x3 and closed with running 3-0 Vicryl suture.  Copious irrigation was used.  Rectus muscle belly was examined and found to be hemostatic and tacked and well approximated in the midline.  At this time, the fascia was closed using 0 Vicryl in a running fashion.  Manual palpation confirms thorough and adequate closure of the fascial layer.  Copious irrigation was again used.  Hemostasis noted, and skin was closed with staples.  The patient tolerated the procedure well.  Sponge, lap, needle, and instrument counts were correct x3 and the patient was sent to the recovery room awake and stable condition.  Infant assumed the care of the intensive care nursery team and being followed and workup up for isoimmunization and fetal anemia.  The patient will be followed for her severe right upper quadrant pain post delivery.  If she continues to have pain, may need a surgical consult for gallbladder and/or angiogram for evaluation of right kidney and questionable venous plexus.  This all will be relayed to Dr. Y, her primary obstetrician who was on call starting this morning at 7 a.m. through the weekend.
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DESCRIPTION: Primary low transverse cesarean section by Pfannenstiel skin incision with bilateral tubal sterilization.   Intrauterine pregnancy at 35-1/7.  Rh isoimmunization.  Suspected fetal anemia.  Desires permanent sterilization.

surgery, intrauterine pregnancy, rh isoimmunization, primary low transverse cesarean section, bilateral tubal sterilization, pfannenstiel skin incision, fascial incision, uterine incision, fetal anemia, permanent sterilization, rectus muscles, incision, tubes, cord,

This case involves a cesarean section at 35 weeks of gestation with complications such as Rh isoimmunization and suspected fetal anemia. The operation is performed due to these risky conditions and also includes bilateral tubal sterilization. Additionally, the infant required immediate intensive care due to being very pale at delivery, suggesting significant concerns about the infant’s health. The situation has potential life-threatening implications for both the mother and the infant, making it a high-stakes scenario.


Medical Specialty: Pain Management
Sample Name: Transforaminal Epidural Steroid Injection

PROCEDURE: , Left L3-L4 transforaminal epidural steroid injection (L3 nerve root) and Left L4-L5 transforaminal epidural steroid injection (L4 nerve root) under fluoroscopic guidance.,PATIENT PROFILE: , This is a 44-year-old female.  The patient reports greatly increasing pain over the past several weeks.  In addition, the patient has associated radicular symptoms of aching, radiating to the L3 dermatome distribution and L4 dermatome distribution.  She is status post posterior fusion and lumbar decompression within the past several years.  Due to the nature of the patient's persistent pain, epidural steroid injection is recommended.  The alternatives, benefits, and risks were discussed with the patient.  The patient verbalized understanding of the risks as well as the alternatives and wished to proceed with the procedure.  A signed and witnessed informed consent was placed on the chart.,PRE-OP DIAGNOSIS:,  Left leg pain, Left leg weakness, Left L3-4 radicular pain, Left L4-5 radicular pain, Lumbar spondylosis.,POST-OP DIAGNOSIS:,  Left leg pain, Left leg weakness, Left L3-4 radicular pain, Left, L4-5 radicular pain, Lumbar spondylosis.,ANESTHESIA:,  Midazolam 2 mg IV Fentanyl 50 mcg IV.,FINDINGS:,PAIN MANAGEMENT:,  The patient reports greatly increasing pain over the past several weeks.  The patient now rates pain as 8/10.  The reported pain is at L3-4 and L4-5.,DESCRIPTION OF PROCEDURE:,  The patient was placed in the prone position on the radiolucent operating table.  The lumbar area was prepped and draped in the appropriate sterile fashion.  The left L3-L4 level was identified for a transforaminal epidural injection and the overlying skin and subcutaneous tissue were anesthetized.  A 22 gauge 3.5 inch B-bevel spinal needle was passed through the skin wheal and advanced in a ventral direction until the tip of the needle was properly placed in the left superior posterior intervertebral foramen as confirmed by AP and lateral fluoroscopic views.  No blood was aspirated.  There was no CSF flow.  Following negative aspiration, 1 mL Isovue-M200 was injected to produce the epidurogram.  There was appropriate needle placement and no intravascular or intrathecal flow.  1 mL of a 40 mg/mL solution of Kenalog and 1 mL of 1% Lidocaine was injected.,Attention was then turned to the next injection.  The lumbar area was prepped and draped in the appropriate sterile fashion.  The left L4-L5 level was identified for a transforaminal epidural injection and a skin wheal was made at the spinal needle entry site.  A 22 gauge 3.5 inch spinal needle was passed through the skin wheal and advanced in a ventral direction until the tip of the needle was properly placed in the left superior posterior intervertebral foramen as confirmed by AP and lateral fluoroscopic views.  No blood was aspirated.  There was no CSF flow.  Following negative aspiration 1 mL Isovue-M200 was injected to produce the epidurogram.  There was appropriate needle placement and no intravascular or intrathecal flow.  1 mL of a 40 mg/mL solution of Kenalog and 1 mL of 1% Lidocaine was injected.  The patient tolerated the procedure well.,DRAINS / DRESSING:,  Applied sterile dressing including BAND-AID.,PATIENT TO RECOVERY ROOM: , The patient tolerated the procedure well, and was brought to the recovery room in excellent condition.,COMPLICATIONS: , No immediate complications,DISCHARGE ORDERS:,DISPOSITION: , Discharge patient to home today.,ACTIVITY: , Patient may resume normal activity level in 1 day.,FOLLOW-UP: , Appointment to Surgeon's Office in 2 weeks,CPT4 CODE(S):,64483 LT, Injection, anesthetic agent and/or steroid, transforaminal epidural; lumbar or sacral, single level.,64484 LT, Injection, anesthetic agent and/or steroid, transforaminal epidural; lumbar or sacral, each additional level (List separately in addition to code for primary procedure).,76005, Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural, transforaminal epidural, subarachnoid, paravertebral facet joint, paravertebral facet joint nerve or sacroiliac joint), including neurolytic agent destruction.,ICD9 CODE(S):,724.4  Thoracic or lumbosacral neuritis or radiculitis.,721.3  Lumbosacral spondylosis without myelopathy.
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DESCRIPTION: Left L3-L4 transforaminal epidural steroid injection (L3 nerve root) and Left L4-L5 transforaminal epidural steroid injection (L4 nerve root) under fluoroscopic guidance.

The procedure described is a transforaminal epidural steroid injection, which is a relatively common and standard intervention in pain management for conditions affecting the lumbar spine. While the procedure is invasive and involves risks such as infection, bleeding, or nerve damage, these are rare when performed by experienced professionals. The patient's understanding and consent suggest that the stakes are understood as moderate, due to potential risks, but not life-threatening. The procedure is well-documented, and the patient was discharged with no complications, supporting the assessment that the stakes are not extremely high.


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

Medical Specialty: General Medicine
Sample Name: Gen Med Progress Note - 5

SUBJECTIVE:,  The patient is a 62-year-old white female with multiple chronic problems including hypertension and a lipometabolism disorder.  She follows with Dr. XYZ on her hypertension, as well as myself.  She continues to gain weight.  Diabetes is therefore a major concern.  In fact, her dad had diabetes and she has a brother who has diabetes.  The patient also has several additional concerns she brings up today.  One is that her left knee continues to bother her and it hurts.  She cannot really isolate where the pain is, it just seems to hurt through her knee.  She has had this for some time now and in fact as we reviewed her records, her left knee has been x-rayed in 1999.  There was some minimal narrowing of the weightbearing joint with some minor hypertrophic spurring medially.  She would like to have this x-rayed again today.  She is certainly not interested in any surgery.  She has noted that it particularly hurts to kneel.  In addition, she complains of her stools being a baby-yellow.  She has rectal bleeding off and on.  It is bright red.  She had a colonoscopy done in 1999.  She does have a family history of colon cancer questionable in her mother, who is deceased.  She complains of some diffuse abdominal pain off and on.  She has given up fast foods and her pop and this has not seemed to help.  She does admit however, that she is not eating right.  Sometimes her stools are hard.  Sometimes they are runny.  The blood does not really seem to be related to necessarily a hard stool.  It is always bright red and will sometimes drip into the toilet.  Over the last couple of days, she had also been sneezing and has had an itchy throat.  She tried some Claritin and this did not help.  She has had some body aches.  She is finally feeling better today with this.  She also is questioning whether she has some sleep apnea.  She will awaken suddenly in the middle of the night.  She was told that she does snore.  She does not smoke.  As stated, she has gained significant weight.,GYNECOLOGICAL HISTORY: , She does not bleed.  She has both ovaries, as well as her uterus and cervix.  She is on no hormonal therapy.,PREVENTATIVE HISTORY:,  She is not exercising.  She does not do self breast examinations.  She has recently had her mammogram and it was unremarkable.  She does take her low-dose aspirin daily as well as her multivitamin.  She does wear her seatbelt.  As previously noted, she does not smoke or drink alcohol.,PAST MEDICAL, FAMILY AND SOCIAL HISTORY:,  Per health summary sheet, unchanged.,REVIEW OF SYSTEMS:,  Unremarkable with the exception of that above. ,ALLERGIES: , No known drug allergies.,CURRENT MEDICATIONS:,  Benicar 20 mg daily; multivitamin; glucosamine; vitamin B complex; vitamin E and a low-dose aspirin.,OBJECTIVE:,General:  Well-nourished, well-developed, a very pleasant 61-year-old in no acute distress.,Vitals:  Her weight today is 246 pounds.  In March of 2002 she weighed 231 pounds.  In March 2001 she weighed 203 pounds.  Her blood pressure is 160/78.  Pulse is 84.  Respiratory rate of 20.  She is afebrile.,HEENT:  Head is of normocephalic, atraumatic.  PERLA.  Conjunctivae clear.  TMs are unremarkable and canals are patent.  Nasal mucosa is slightly reddened.  Nares are patent.  Throat shows some clear posterior pharyngeal drainage.  Throat is slightly reddened.  Non-exudative.  No oral lesions or dental caries noted.,Neck:  Supple, No adenopathy.  Thyroid without any nodules or enlargements, no JVD or carotid bruits.,Heart:  Regular rate and rhythm without murmurs, clicks or rubs.  PMI is nondisplaced.,Lungs:  Clear to A&P.  No CVA tenderness.,Breast exam:  Negative for any axillary nodes, skin changes, discrete nodules or nipple discharge.  Breasts were examined both lying and sitting.,Abdomen:  Soft, nondistended, normoactive bowel sounds, no hepatosplenomegaly or masses.  Non tender.,Pelvic exam:  BUS unremarkable.  Speculum exam shows normal physiologic discharge.  There are some atrophic vaginal changes.  Cervix visualized, no gross abnormalities.  Pap smear obtained.  Bimanual is negative for any adnexal masses or tenderness.  Rectal exam is negative for any adnexal masses or tenderness.  No rectal masses.  She does have some external hemorrhoids, none of which are inflamed at this time.  No palpable rectal masses.,Neuromusculoskeletal exam:  Cranial nerves II-XII are grossly intact.  No cerebellar signs are noted.  No evidence of a gait disturbance.  DTRs are 1+/4+ and equal throughout.  Good uptoeing.  Skin:  Inspection of her skin, subcuticular tissues negative for any concerning skin lesions, rashes or subcuticular masses.,ASSESSMENT:,1.  Weight-gain.,2.  Hypertension.,3.  Lipometabolism disorder.,4.  Rectal bleeding.,5.  Left knee pain.,6.  Question of sleep apnea.,7.  Upper respiratory infection, improving.,8.  Gynecological examination is unremarkable for her age.,PLAN:,  We discussed at length, the issue of sleep apnea and its negative sequela.  I have recommended that she be referred for a sleep study.  She is certainly at risk for sleep apnea.  She refuses this.  I do not think that her upper respiratory tract infection needs any further treatment at this time since she is feeling better.  I did x-ray her knee and with the exception of some degenerative changes, it was unremarkable.  I reviewed this with her.  I do think that since she is having rectal bleeding, while this is not real unusual for her, with her family history of colon cancer, I am going to have her discuss this further with Dr. XYZ and leave further studies up to them.  I will dictate Dr. XYZ a note.  I am not going to order any further studies at this time in terms of her yellow stools and right upper quadrant discomfort.  She has had a gallbladder sonogram done in the past, this has been unremarkable and these symptoms really have not changed for her.  This however, has been some time ago.  I suspect she has an element of irritable bowel syndrome.  I have strongly encouraged weight reduction, both through diet and exercise.  I would like to see her back in the office in six months.  I did retake her blood pressure today and it was 130/70.  She is fasting this morning, so we will get a fasting blood sugar, chem-12, lipid profile, and CPK.  I will her mail the results.  I have strongly encouraged medication management if her lipids are elevated.  I think she is amenable to this.  Her DEXA scan is up to date having been done on 04/09/03.  I do not recommend one this year.
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DESCRIPTION: A 62-year-old white female with multiple chronic problems including hypertension and a lipometabolism disorder.

The situation involves the management of chronic health issues such as hypertension, potential diabetes, sleep apnea, possible irritable bowel syndrome, and concerns like rectal bleeding which could be indicative of more serious conditions like colon cancer. While the patient is not in immediate critical condition, these chronic conditions require careful monitoring and management due to their potential impact on the patient's health. Failure to adequately manage these could lead to significant deterioration in her health. Thus, it is moderately high-stakes as it involves potentially serious health outcomes over time and requires coordinated care from multiple practitioners.


Medical Specialty: Consult - History and Phy.
Sample Name: Sports Physical - 2

CHIEF COMPLAINT:,  Well-child check sports physical.,HISTORY OF PRESENT ILLNESS:,  This is a 14-1/2-year-old white male known to have asthma and allergic rhinitis.  He is here with his mother for a well-child check.  Mother states he has been doing well with regard to his asthma and allergies.  He is currently on immunotherapy and also takes Advair 500/50 mg, Flonase, Claritin and albuterol inhaler as needed.  His last exacerbation was 04/04.  He has been very competitive in his sports this spring and summer and has had no issues since that time.  He eats well from all food groups.  He has very good calcium intake.  He will be attending Maize High School in the ninth grade.  He has same-sex and opposite-sex friends.  He has had a girlfriend in the past.  He denies any sexual activity.  No use of alcohol, cigarettes or other drugs.  His bowel movements are without problems.  His immunizations are up to date.  His last tetanus booster was in 07/03.,CURRENT MEDICATIONS:,  As above.,ALLERGIES: , He has no known medication allergies.,REVIEW OF SYSTEMS:,Constitutional:  He has had no fever.,HEENT:  No vision problems.  No eye redness, itching or drainage.  No earache.  No sore throat or congestion.,Cardiovascular:  No chest pain.,Respiratory:  No cough, shortness of breath or wheezing.,GI:  No stomachache, vomiting or diarrhea.,GU:  No dysuria, urgency or frequency.,Hematological:  No excessive bruising or bleeding.  He did have a minor concussion in 06/04 while playing baseball.,PHYSICAL EXAMINATION:,General:  He is alert and in no distress.,Vital signs:  He is afebrile.  His weight is at the 75th percentile.  His height is about the 80th percentile.,HEENT:  Normocephalic.  Atraumatic.  Pupils are equal, round and reactive to light.  TMs are clear bilaterally.  Nares patent.  Nasal mucosa is mildly edematous and pink.  No secretions.  Oropharynx is clear.,Neck:  Supple.,Lungs:  Good air exchange bilaterally.,Heart:  Regular.  No murmur.,Abdomen:  Soft.  Positive bowel sounds.  No masses.  No hepatosplenomegaly.,GU:  Male.  Testes descended bilaterally.  Tanner IV.  No hernia appreciated.,Extremities:  Symmetrical.  Femoral pulses 2+ bilaterally.  Full range of motion of all extremities.,Back:  No scoliosis.,Neurological:  Grossly intact.,Skin:  Normal turgor.  Minor sunburn on upper back.,Neurological:  Grossly intact.,ASSESSMENT:,1.  Well child.,2.  Asthma with good control.,3.  Allergic rhinitis, stable.,PLAN:,  Hearing and vision assessment today are both within normal limits.  Will check an H&H today.  Continue all medications as directed.  Prescription written for albuterol inhaler, #2, one for home and one for school to be used for rescue.  Anticipatory guidance for age.  He is to return to the office in one year or sooner if needed.
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DESCRIPTION: Well-child check sports physical - Well child asthma with good control, allergic rhinitis.

The situation involves a routine well-child check and sports physical for a 14-year-old male with well-controlled asthma and allergic rhinitis. There are no acute issues or urgent concerns raised in the examination, and the patient is currently doing well with his current treatment regimen. This indicates that the stakes are low, as the visit is routine and does not involve any immediate or severe health concerns.