Medical Specialty: Dentistry
Sample Name: Full Mouth Dental Rehabilitation - 1

OPERATION PERFORMED:,  Full mouth dental rehabilitation in the operating room under general anesthesia.,PREOPERATIVE DIAGNOSES:  ,1.  Severe dental caries.,2.  Hemophilia.,POSTOPERATIVE DIAGNOSES:  ,1.  Severe dental caries.,2.  Hemophilia.,3.  Nonrestorable teeth.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Minimal.,DURATION OF SURGERY:  ,1 hour and 22 minutes.,BRIEF HISTORY:  ,The patient was first seen by me on 08/23/2007, who is 4-year-old with hemophilia, who received infusion on Tuesdays and Thursdays and he has a MediPort.  Mom reported history of high fever after surgery and he has one seizure previously.  He has history of trauma to his front teeth and physician put him on antibiotics.  He was only cooperative for having me do a visual examination on his anterior teeth.  Visual examination revealed severe dental caries and dental abscess from tooth #E and his maxillary anterior teeth needed to be extracted.  Due to his young age and hemophilia, I felt that he would be best served to be taken to the hospital operating room.,OTHER PREPARATION:  ,The child was brought to the Hospital Day Surgery accompanied by his mother.  There, I met with her and discussed the needs of the child, types of restoration to be performed, and the risks, and benefits of the treatment as well as the options and alternatives of the treatment.  After all her questions and concerns were addressed, she gave her informed consent to proceed with treatment.  The patient's history and physical examination was reviewed.  He was given factor for appropriately for his hemophilia prior to being taken back to the operating room.  Once he was cleared by Anesthesia, the child was taken back to the operating room.,OPERATIVE PROCEDURE:  ,The patient was placed on the surgical table in the usual supine position with all extremities protected.  Anesthesia was induced by mask.  The patient was then intubated with an oral tube and the tube was stabilized.  The head was wrapped and IV was started.  The head and neck were draped with sterile towels and the body was covered with a lead apron and sterile sheath.  A moist continuous throat pack was placed beyond tonsillar pillars.  Plastic lip and cheek retractors were then placed.  Preoperative clinical photographs were taken.  Two posterior bitewing radiographs and two anterior periapical films were taken in the operating room with digital radiograph.  After the radiographs were taken, the lead shield was removed.,Prophylaxis was then performed using a prophy cup and fluoridated prophy paste.  The patient's teeth were rinsed well.  The patient's oral cavity was suctioned clean.  Clinical and radiographic examination followed and areas of decay were noted.  During the restorative phase, these areas of decay were incidentally removed.  Entry was made to the level of the dental-enamel junction and beyond as necessary to remove it.  Final caries removal was confirmed upon reaching hard, firm and sound dentin.,Teeth restored with composite ___________  bonded with a one-step bonding agent.  Teeth restored with amalgam had a dentin tubular seal placed prior to amalgam placement.  Non-restorable primary teeth would be extracted.  The caries were extensive and invaded the pulp tissues, pulp therapy was initiated using ViscoStat and then IRM pulpotomies.  Teeth treated in such a manner would then be crowned with stainless steel crowns.,Upon conclusion of the restorative phase, the oral cavity was aspirated and found to be free of blood, mucus, and other debris.  The original treatment plan was verified with the actual treatment provided.  Postoperative clinical photographs were then taken.  The continuous gauze throat pack was removed with continuous suction with visualization.  Topical fluoride was then placed on the teeth.  At the end of the procedure, the child was undraped, extubated, and awakened in the operating room, was taken to the recovery room, breathing spontaneously with stable vital signs.,FINDINGS: , This young patient presented with mild generalized marginal gingivitis, secondary to light generalized plaque accumulation and fair oral hygiene.  All primary teeth were present.  Dental carries were present on the following teeth:  Tooth B, OL caries, tooth C, M, L, S caries, tooth B, caries on all surfaces, tooth E caries on all surfaces, tooth F caries on all surfaces, tooth T caries on all surfaces, tooth H, lingual and facial caries, tooth I, caries on all surfaces, tooth L caries on all surfaces, and tooth S, all caries.  The remainder of his teeth and soft tissues were within normal limits.  The following restoration and procedures were performed.  Tooth B, OL amalgam, tooth C, M, L, S composite, tooth D, E, F, and G were extracted, tooth H, and L and separate F composite.  Tooth I is stainless steel crown, tooth L pulpotomy and stainless steel crown and tooth S no amalgam.  Sutures were also placed at extraction site D, E, S, and G.,CONCLUSION:  ,The mother was informed of the completion of the procedure.  She was given a synopsis of the treatment provided as well as written and verbal instructions for postoperative care.  She is to contact to myself with an event of immediate postoperative complications and after full recovery, he was discharged from recovery room in the care of his mother.  She was also given prescription for Tylenol with Codeine Elixir for postoperative pain control.,
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DESCRIPTION: Full mouth dental rehabilitation in the operating room under general anesthesia.

The situation involves a full mouth dental rehabilitation for a 4-year-old patient with hemophilia, conducted under general anesthesia. The young age of the patient and the presence of hemophilia, which affects blood clotting, increase the stakes of the procedure due to the risk of excessive bleeding. Additionally, general anesthesia itself carries risks, especially with a history of post-surgical high fever and a previous seizure. Ensuring safe anesthesia management and controlling bleeding are critical aspects, making this a high-stakes procedure compared to standard dental work without these complicating factors.


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

Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Bronchoalveolar lavage.

POSTOPERATIVE DIAGNOSIS:  Fever.,PROCEDURES:  Bronchoalveolar lavage.,INDICATIONS FOR PROCEDURE:  The patient is a 28-year-old male, status post abdominal trauma, splenic laceration, and splenectomy performed at the outside hospital, who was admitted to the Trauma Intensive Care Unit on the evening of August 4, 2008.  Greater than 24 hours postoperative, the patient began to run a fever in excess of 102.  Therefore, evaluation of his airway for possible bacterial infection was performed using bronchoalveolar lavage.,DESCRIPTION OF PROCEDURE:  The patient was preoxygenated with 100% FIO2 for approximately 5 to 10 minutes prior to the procedure.  The correct patient and procedure was identified by time out by all members of the team.  The patient was prepped and draped in a sterile fashion and sterile technique was used to connect the BAL lavage catheter to Lukens trap suction.  A catheter was introduced into the endotracheal tube through a T connector and five successive 20 mL aliquots of normal saline were flushed through the catheter, each time suctioning out the sample into the Lukens trap.  A total volume of 30 to 40 mL was collected in the trap and sent to the lab for quantitative bacteriology.  The patient tolerated the procedure well and had no episodes of desaturation, apnea, or cardiac arrhythmia.  A postoperative chest x-ray was obtained.
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DESCRIPTION: Evaluation of airway for possible bacterial infection performed using bronchoalveolar lavage.

cardiovascular / pulmonary, abdominal trauma, bal lavage, lukens trap suction, splenectomy, splenic laceration, bronchoalveolar lavage, fever, catheter, bronchoalveolar, lavage, airwayNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

The situation involves a postoperative evaluation of a patient's airway for possible bacterial infection using bronchoalveolar lavage, a diagnostic procedure. This is being done because the patient, who is recovering from abdominal trauma and splenectomy, has developed a high fever, which may indicate a serious underlying infection. The stakes are relatively high due to the potential for significant complications if the infection is not identified and treated promptly. However, since the immediate procedure was conducted successfully and without complications, it's not at the highest end of the risk spectrum.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Surgery
Sample Name: PMT Halo Crown & Vest

PREOPERATIVE DIAGNOSES: , Cervical spondylosis, status post complex anterior cervical discectomy, corpectomy, decompression and fusion.,POSTOPERATIVE DIAGNOSES: , Cervical spondylosis, status post complex anterior cervical discectomy, corpectomy, decompression and fusion, and potentially unstable cervical spine.,OPERATIVE PROCEDURE:  ,Application of PMT large halo crown and vest.,ESTIMATED BLOOD LOSS: , None.,ANESTHESIA:  ,Local, conscious sedation with Morphine and Versed.,COMPLICATIONS: , None.  Post-fixation x-rays, nonalignment, no new changes.  Post-fixation neurologic examination normal.,CLINICAL HISTORY:  ,The patient is a 41-year-old female who presented to me with severe cervical spondylosis and myelopathy.  She was referred to me by Dr. X.  The patient underwent a complicated anterior cervical discectomy, 2-level corpectomy, spinal cord decompression and fusion with fibular strut and machine allograft in the large cervical plate.  Surgery had gone well, and the patient has done well in the last 2 days.  She is neurologically improved and is moving all four extremities.  No airway issues.  It was felt that the patient was now a candidate for a halo vest placement given that chance of going to the OR were much smaller.  She was consented for the procedure, and I sought the help of ABC and felt that a PMT halo would be preferable to a Bremer halo vest.  The patient had this procedure done at the bedside, in the SICU room #1.  I used a combination of some morphine 1 mg and Versed 2 mg for this procedure.  I also used local anesthetic, with 1% Xylocaine and epinephrine a total of 15 to 20 cc.,PROCEDURE DETAILS:,  The patient's head was positioned on some towels, the retroauricular region was shaved, and the forehead and the posterolateral periauricular regions were prepped with Betadine.  A large PMT crown was brought in and fixed to the skull with pins under local anesthetic.  Excellent fixation achieved.  It was lateral to the supraorbital nerves and 1 fingerbreadth above the brows and the ear pinnae.,I then put the vest on, by sitting the patient up, stabilizing her neck.  The vest was brought in from the front as well and connected.  Head was tilted appropriately, slightly extended, and in the midline.  All connections were secured and pins were torqued and tightened.,During the procedure, the patient did fine with no significant pain.,Post-procedure, she is neurologically intact and she remained intact throughout.  X-rays of the cervical spine AP, lateral, and swimmer views showed excellent alignment of the hardware construct in the graft with no new changes.,The patient will be subjected to a CT scan to further define the alignment, and barring any problems, she will be ambulating with the halo on.,The patient will undergo pin site care as per protocol, and likely she will go in the next 2 to 3 days.  Her prognosis indeed is excellent, and she is already about 90% or so better from her surgery.  She is also on a short course of Decadron, which we will wean off in due course.,The matter was discussed with the patient and the patient's family.
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DESCRIPTION: Application of PMT large halo crown and vest.  Cervical spondylosis, status post complex anterior cervical discectomy, corpectomy, decompression and fusion.

surgery, cervical spondylosis, anterior cervical discectomy, corpectomy, decompression, fusion, pmt, crown, vest, pmt halo, cervical,

The procedure described involves applying a PMT halo crown and vest to stabilize a patient's cervical spine after a complex surgery. While the immediate procedure seems to have gone smoothly without complications, the patient's condition involves a potentially unstable cervical spine, which is critical and requires careful management. Although the surgery outcome appears positive, the inherent risks of spinal instability and the patient's dependency on the halo for stabilization denote a high-stakes situation. However, since the surgery is deemed successful and the patient is neurologically intact, the stakes are lowered slightly compared to an acute emergency.


Medical Specialty: Radiology
Sample Name: Radiofrequency Thermocoagulation - 2

PREOPERATIVE DIAGNOSIS:,  Complex Regional Pain Syndrome Type I.,POSTOPERATIVE DIAGNOSIS: , Same.,PROCEDURE:,1.  Stellate ganglion RFTC (radiofrequency thermocoagulation)  left side.,2.  Interpretation of Radiograph.,ANESTHESIA:  ,IV Sedation with Versed and Fentanyl.,ESTIMATED BLOOD LOSS:,  None.,COMPLICATIONS:,  None.,INDICATIONS: , Patient with reflex sympathetic dystrophy, left side.  Positive for allodynia, pain, mottled appearance, skin changes upper extremities as well as swelling.,SUMMARY OF PROCEDURE: , Patient is admitted to the Operating Room.  Monitors placed, including EKG, Pulse oximeter, and BP cuff.  Patient had a pillow placed under the shoulder blades.  The head and neck was allowed to fall back into hyperextension.  The neck region was prepped and draped in sterile fashion with Betadine and alcohol.  Four sterile towels were placed.  The cricothyroid membrane was palpated, then going one finger's breadth lateral from the cricothyroid membrane and one finger's breadth inferior, the carotid pulse was palpated and the sheath was retracted laterally.  A 22 gauge SMK 5-mm bare tipped needle was then introduced in between the cricothyroid membrane and the carotid sheath and directed inferiomedially.  The needle is advanced prudently through the tissues, avoiding the carotid artery laterally.  The tip of the needle is perceived to intersect with the vertebral body of Cervical #7 and this was visualized by fluoroscopy.  Aspiration was cautiously performed after the needle was retracted approximately 1 mm and held steady with left hand.  No venous or arterial blood return is noted.  No cerebral spinal fluid is noted.  Positive sensory stimulation was elicited using the Radionics unit at 50 Hz from 0-0.1 volts and negative motor stimulation was elicited from 1-10 volts at 2 Hz.  After negative aspiration through the 22 gauge SMK 5mm bare tipped needle is absolutely confirmed, 5 cc of solution (solution consisting of 5 cc of 0.5% Marcaine, 1 cc of triamcinolone) was then injected into the stellate ganglion region.  This was done with intermittent aspiration vigilantly verifying negative aspiration.  The stylet was then promptly replaced and neurolysis (nerve decompression) was then carried out for 60 seconds at 80 degrees centigrade.  This exact same procedure using the exact same protocol was repeated one more time to complete the two lesions of the stellate ganglion.  The patient was immediately placed in the sitting position to reduce any side effect from the stellate ganglion block associated with cephalad spread of the solution.  Pressure was placed over the puncture site for approximately five minutes to eliminate any hemorrhage from blood vessels that may have been punctured and a Band-Aid was placed over the puncture site.  Patient was monitored for an additional ten to fifteen minutes and was noted to have tolerated the procedure well without any adverse sequelae.  Significant temperature elevation was noted on the affected side verifying neurolysis of the ganglion.  ,Interpretation of radiograph reveals placement of the 22-gauge SMK 5-mm bare tipped needle in the region of the stellate ganglion on the affected side.  Four lesions were carried out.
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DESCRIPTION: Complex Regional Pain Syndrome Type I.  Stellate ganglion RFTC (radiofrequency thermocoagulation)  left side and interpretation of Radiograph.

radiology, sheath, vertebral body, regional pain syndrome, radiofrequency thermocoagulation, stellate ganglion, rftc, radiofrequency, radiograph, cricothyroid, thermocoagulation, ganglion,

The situation presented involves a medical procedure for treating Complex Regional Pain Syndrome Type I, specifically through stellate ganglion radiofrequency thermocoagulation. The procedure involves careful navigation and execution to avoid complications such as damage to the carotid artery or other critical structures in the neck. While it appears routine for a trained practitioner and the procedure summary notes no complications, the consequences of an error could be significant, such as nerve damage or vascular injury. Therefore, it involves moderately high stakes due to the precision required and the potential risks.


Medical Specialty: Orthopedic
Sample Name: Pain Management Consult - 1

Mr. XYZ forgot his hearing aids at home today and is severely hearing impaired and most of the interview had to be conducted with me yelling at him at the top of my voice.  For all these reasons, this was not really under the best circumstances and I had to curtail the amount of time I spent trying to get a history because of the physical effort required in extracting information from this patient.  The patient was seen late because he had not filled in the patient questionnaire.  To summarize the history here, Mr. XYZ who is not very clear on events from the past, sustained a work-related injury some time in 1998.  At that time, he was driving an 18-wheeler truck.  The patient indicated that he slipped off the rear of his truck while loading vehicles to his trailer.  He experienced severe low back pain and eventually a short while later, underwent a fusion of L4-L5 and L5-S1.  The patient had an uneventful hospital course from the surgery, which was done somewhere in Florida by a surgeon, who he does not remember.  He was able to return to his usual occupation, but then again had a second work-related injury in May of 2005.  At that time, he was required to boat trucks to his rig and also to use a chain-pulley system to raise and lower the vehicles.  Mr. XYZ felt a popping sound in his back and had excruciating low back pain and had to be transported to the nearest hospital.  He was MRI'ed at that time, which apparently showed a re-herniation of an L5-S1 disc and then, he somehow ended up in Houston, where he underwent fusion by Dr. W from L3 through S2.  This was done on 12/15/2005.  Initially, he did fairly well and was able to walk and move around, but then gradually the pain reappeared and he started getting severe left-sided leg pain going down the lateral aspect of the left leg into his foot.  He is still complaining of the severe pain right now with tingling in the medial two toes of the foot and significant weakness in his left leg.  The patient was referred to Dr. A, pain management specialist and Dr. A has maintained him on opioid medications consisting of Norco 10/325 mg for breakthrough pain and oxycodone 30 mg t.i.d. with Lunesta 3 mg q.h.s. for sleep, Carisoprodol 350 mg t.i.d., and Lyrica 100 mg q.daily.  The patient states that he is experiencing no side effects from medications and takes medications as required.  He has apparently been drug screened and his drug screening has been found to be normal.  The patient underwent an extensive behavioral evaluation on 05/22/06 by TIR Rehab Center.  At that time, it was felt that Mr. XYZ showed a degree of moderate level of depression.  There were no indications in the evaluation that Mr. XYZ showed any addictive or noncompliant type behaviors.  It was felt at that time that Mr. XYZ would benefit from a brief period of individual psychotherapy and a course of psychotropic medications.  Of concern to the therapist at that time was the patient's untreated and unmonitored hypertension and diabetes.  Mr. XYZ indicated at that time, they had not purchased any prescription medications or any of these health-related issues because of financial limitations.  He still apparently is not under really good treatment for either of these conditions and on today's evaluation, he actually denies that he had diabetes.  The impression was that the patient had axis IV diagnosis of chronic functional limitations, financial loss, and low losses with no axis III diagnosis.  This was done by Rhonda Ackerman, Ph.D., a psychologist.  It was also suggested at that time that the patient should quit smoking.  Despite these evaluations, Mr. XYZ really did not get involved in psychotherapy and there was poor attendance of these visits, there was no clearance given for any surgical interventions and it was felt that the patient has benefited from the use of SSRIs.  Of concern in June of 2006 was that the patient had still not stopped smoking despite warnings.  His hypertension and diabetes were still not under good control and the patient was assessed at significant risk for additional health complications including stroke, reduced mental clarity, and future falls.  It was felt that any surgical interventions should be put on hold at that time.  In September of 2006, the patient was evaluated at Baylor College of Medicine in the Occupational Health Program.  The evaluation was done by a physician at that time, whose report is clearly documented in the record.  Evaluation was done by Dr. B.  At present, Mr. XYZ continues on with his oxycodone and Norco.  These were prescribed by Dr. A two and a half weeks ago and the patient states that he has enough medication left to last him for about another two and a half weeks.  The patient states that there has been no recent change in either the severity or the distribution of his pain.  He is unable to sleep because of pain and his activities of daily living are severely limited.  He spends most of his day lying on the floor, watching TV and occasionally will walk a while.  ***** from detailed questioning shows that his activities of daily living are practically zero.  The patient denies smoking at this time.  He denies alcohol use or aberrant drug use.  He obtains no pain medications from no other sources.  Review of MRI done on 02/10/06 shows laminectomies at L3 through S1 with bilateral posterior plates and pedicle screws with granulation tissue around the thecal sac and around the left L4-5 and S1 nerve roots, which appear to be retracted posteriorly.  There is a small right posterior herniation at L1-L2.,PAST MEDICAL HISTORY:,  Significant for hypertension, hypercholesterolemia and non-insulin-dependent diabetes mellitus.  The patient does not know what medications he is taking for diabetes and denies any diabetes.  CABG in July of 2006 with no preoperative angina, shortness of breath, or myocardial infarction.  History of depression, lumbar fusion surgery in 2000, left knee surgery 25 years ago.,SOCIAL HISTORY:,  The patient is on disability.  He does not smoke.  He does not drink alcohol.  He is single.  He lives with a girlfriend.  He has minimal activities of daily living.  The patient cannot recollect when last a urine drug screen was done.,REVIEW OF SYSTEMS:,  No fevers, no headaches, chest pain, nausea, shortness of breath, or change in appetite.  Depressive symptoms of crying and decreased self-worth have been noted in the past.  No neurological history of strokes, epileptic seizures.  Genitourinary negative.  Gastrointestinal negative.  Integumentary negative.  Behavioral, depression.,PHYSICAL EXAMINATION:,  The patient is short of hearing.  His cognitive skills appear to be significantly impaired.  The patient is oriented x3 to time and place.  Weight 185 pounds, temperature 97.5, blood pressure 137/92, pulse 61.  The patient is complaining of pain of a 9/10.,Musculoskeletal:  The patient's gait is markedly antalgic with predominant weightbearing on the left leg.  There is marked postural deviation to the left.  Because of pain, the patient is unable to heel-toe or tandem gait.  Examination of the neck and cervical spine are within normal limits.  Range of motion of the elbow, shoulders are within normal limits.  No muscle spasm or abnormal muscle movements noted in the neck and upper extremities.  Head is normocephalic.  Examination of the anterior neck is within normal limits.  There is significant muscle wasting of the quadriceps and hamstrings on the left, as well as of the calf muscles.  Skin is normal.  Hair distribution normal.  Skin temperature normal in both the upper and lower extremities.  The lumbar spine curvature is markedly flattened.  There is a well-healed central scar extending from T12 to L1.  The patient exhibits numerous positive Waddell's signs on exam of the low back with inappropriate flinching and wincing with even the lightest touch on the paraspinal muscles.  Examination of the paraspinal muscles show a mild to moderate degree of spasm with a significant degree of tenderness and guarding, worse on the left than the right.  Range of motion testing of the lumbar spine is labored in all directions.  It is interesting that the patient cannot flex more than 5  in the standing position, but is able to sit without any problem.  There is a marked degree of sciatic notch tenderness on the left.  No abnormal muscle spasms or muscle movements were noted.  Patrick's test is negative bilaterally.  There are no provocative facetal signs in either the left or right quadrants of the lumbar area.  Neurological exam:  Cranial nerves II through XII are within normal limits.  Neurological exam of the upper extremities is within normal limits with good motor strength and normal biceps, triceps and brachioradialis reflexes.  Neurological exam of the lower extremities shows a 2+ right patellar reflex and -1 on the left.  There is no ankle clonus.  Babinski is negative.  Sensory testing shows a minimal degree of sensory loss on the right L5 distribution.  Muscle testing shows decreased L4-L5 on the left with extensor hallucis longus +2/5.  Ankle extensors are -3 on the left and +5 on the right.  Dorsiflexors of the left ankle are +2 on the left and +5 on the right.  Straight leg raising test is positive on the left at about 35 .  There is no ankle clonus.  Hoffman's test and Tinel's test are normal in the upper extremities.,Respiratory:  Breath sounds normal.  Trachea is midline.,Cardiovascular:  Heart sounds normal.  No gallops or murmurs heard.  Carotid pulses present.  No carotid bruits.  Peripheral pulses are palpable.,Abdomen:  Hernia site is intact.  No hepatosplenomegaly.  No masses.  No areas of tenderness or guarding.,IMPRESSION:,1.  Post-laminectomy low back syndrome.,2.  Left L5-S1 radiculopathy.,3.  Severe cognitive impairment with minimal ***** for rehabilitation or return to work.,4.  Opioid dependence for pain control.,TREATMENT PLAN:,  The patient will continue on with his medications prescribed by Dr. Chang and I will see him in two weeks' time and probably suggest switching over from OxyContin to methadone.  I do not think this patient is a good candidate for spinal cord stimulation due to his grasp of exactly what is happening and his cognitive impairment.  I will get a behavioral evaluation from Mr. Tom Welbeck and refer the patient for ongoing physical therapy.  The prognosis here for any improvement or return to work is zero.
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DESCRIPTION: Pain management for post-laminectomy low back syndrome and radiculopathy.

orthopedic, pain management, opioid dependence, patrick's test, behavioral evaluation, cognitive impairment, low back syndrome, motor strength, pain control, physical therapy, radiculopathy, spinal cord stimulation, activities of daily living, neurological exam, laminectomy, hearing, diabetes, muscle, syndrome,

This situation involves a patient with severe chronic pain management issues, post-operative complications, and significant cognitive impairment, compounded by socioeconomic challenges impacting his access to care. While these factors are serious and impact the patient's quality of life, the situation is primarily a management of ongoing chronic conditions rather than an immediate life-threatening crisis. However, the patient's unmanaged hypertension and diabetes pose risks for future complications. The review and adjustment of medications, as well as the concerns about opioid dependence, add complexity, but the treatment plan is stable with follow-up actions in place. The stakes are significant for the patient's well-being but not acutely life-threatening at this moment.


Medical Specialty: General Medicine
Sample Name: Discharge Summary - 16

ADMISSION DIAGNOSIS: , Upper respiratory illness with apnea, possible pertussis.,DISCHARGE DIAGNOSIS: , Upper respiratory illness with apnea, possible pertussis.,COMPLICATIONS: , None.,OPERATIONS: , None,BRIEF HISTORY AND PHYSICAL: , This is a one plus-month-old female with respiratory symptoms for approximately a week prior to admission.  This involved cough, post-tussive emesis, questionable fever, but only 99.7.  Their usual doctor prescribed amoxicillin over the phone.  The coughing persisted and worsened.  She went to the ER, where sats were normal at baseline, but dropped into the 80s with coughing spells.  They did witness some apnea.  They gave some Rocephin, did some labs, and the patient was transferred to hospital.,PHYSICAL EXAMINATION: , On admission, GENERAL:  Well-developed, well-nourished baby in no apparent distress. HEENT:  There was some nasal discharge.  Remainder of the HEENT was normal.  LUNG:  Had few rhonchi.  No retractions.  No significant coughing or apnea during the admission physical.  ABDOMEN:  Benign.  EXTREMITIES:  Were without any cyanosis.,SIGNIFICANT LABS AND X-RAYS:  ,She had a CBC done Garberville, which showed a white count of 12.4, with a differential of 10 segs, 82 lymphs, 8 monos, hemoglobin of 15, hematocrit 42, platelets 296,000, and a normal BMP.  An x-ray was done and I do not have an official interpretation, but to the admitting physician, Dr. X it showed no significant infiltrate.  Well at hospital, she had a rapid influenza swab done, which was negative.  She had a rapid RSV done, which is still not in the chart, but I believe I was told that it was negative.  She also had a pertussis PCR swab done and a pertussis culture done, neither of which has result in the chart.  I do know that the pertussis culture proved to be negative.,CONSULTATION: , Public Health Department was notified of a case of suspected pertussis.,HOSPITAL COURSE: , The baby was afebrile.  Required no oxygen in the hospital.  Actually fed reasonably well.  Did have one episode of coughing with slight emesis.  Appeared basically quite well between episodes.  Had no apnea witnessed and after overnight observation, the parents were anxious to go home.  The patient was started on Zithromax in the hospital.,CONDITION AND TREATMENT: , The patient was in stable condition and good condition on exam at the time and was discharged home on Zithromax to be followed up in the office within a week.,INSTRUCTIONS TO PATIENT:,  Include usual diet and to follow up within a week, but certainly sooner if the coughing is worse and there is cyanosis or apnea again.
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DESCRIPTION: Upper respiratory illness with apnea, possible pertussis.  a one plus-month-old female with respiratory symptoms for approximately a week prior to admission.  This involved cough, post-tussive emesis, and questionable fever.

general medicine, emesis, cough, upper respiratory illness, respiratory illness, apnea, pertussis,

The discharge summary indicates that the infant was diagnosed with an upper respiratory illness with apnea and possible pertussis, which required hospital admission and observation. Pertussis is a serious condition, particularly in young infants, due to the risk of severe coughing that can lead to apnea and potentially fatal complications. However, the baby was stable upon discharge, with no witnessed apnea and in good condition. The follow-up instructions were to monitor for signs of worsening such as cyanosis or apnea, which denotes some level of residual risk. Despite this, there were no severe complications noted during hospitalization, no need for oxygen, and the treatment was effectively managed with antibiotics. Therefore, while the situation was concerning, especially given the age of the patient, the stakes upon discharge were not critically high, but vigilance is required.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Angiogram & Angioplasty

PREOPERATIVE DIAGNOSES:,1.  Left superficial femoral artery subtotal stenosis.,2.  Arterial insufficiency, left lower extremity.,POSTOPERATIVE DIAGNOSES:,1.  Left superficial femoral artery subtotal stenosis.,2.  Arterial insufficiency, left lower extremity.,OPERATIONS PERFORMED:,1.  Left lower extremity angiogram.,2.  Left superficial femoral artery laser atherectomy.,3.  Left superficial femoral artery percutaneous transluminal balloon angioplasty.  ,4.  Left external iliac artery angioplasty.,5.  Left external iliac artery stent placement.,6.  Completion angiogram.,FINDINGS:  ,This patient was brought to the OR with a non-severe stenosis of the proximal left superficial femoral artery in the upper one-third of his thigh.  He is also known to have severe calcific disease involving the entire left external iliac system as well as the common femoral and deep femoral arteries.,Our initial plan today was to perform an atherectomy with angioplasty and stenting of the left superficial femoral artery as necessary.  However, whenever we started the procedure, it became clear that there was a severe stenosis of the left superficial femoral artery at its takeoff from the left common femoral artery.  The area was severely calcified including the external iliac artery extending up underneath the left inguinal ligament.  Indeed, this ultimately was dissected due to manipulation of sheath catheters and sheath through the area.  Ultimately, this wound up being a much more complex case than initially anticipated.,Because of the above, we ultimately performed a laser atherectomy of the left superficial femoral artery, which then had to be angioplastied to obtain a satisfactory result.  The completion angiogram showed that there was a dissection of the left external iliac artery, which precluded flow down into the left lower extremity.  We then had to come up and perform angioplasty and stenting of the left external iliac artery as well as aggressively dilating the takeoff of the less superficial femoral artery from the common femoral artery.,The left superficial femoral artery was dilated with a 6-mm balloon.,The left external iliac artery and common femoral arteries were dilated with an 8-mm balloon.,A 2.5-mm ClearPath laser probe was used to initially arthrectomize and debulk the superficial femoral artery starting at its takeoff from the common femoral artery and extending down to the tight stenotic area in the upper one-third of the thigh.  After the laser atherectomy was performed, the area still did not look good and so an angioplasty was then done, which looked good; however, as noted above, after we had dealt with the superficial femoral artery, we then had proximal inflow problems, which had to be dealt by angioplasty and stenting.,The patient had good dorsalis pedis pulses bilaterally upon completion.,The right common femoral artery was used for access in an up-and-over technique.,PROCEDURE: , With the patient in the supine position under general anesthesia, the abdomen and lower extremities were prepped and draped in the sterile fashion.,The right common femoral artery was punctured percutaneously, and a #5-French sheath was initially placed.  We used a pigtail catheter to go up and over the aortic bifurcation and placed a stiff Amplatz guidewire down into the left common femoral artery.  We then heparinized the patient and placed a #7-French Raby sheath over the Amplatz wire.  A selective left lower extremity angiogram was then done with the above-noted findings.,We then used a ClearPath 2.5-mm laser probe to laser the proximal superficial femoral artery.  Because of the findings as noted above, this became more involved than initially hoped for.  Once the laser atherectomy had been completed, the vessel still did not look good, so we used a 6-mm balloon to thoroughly dilate the area.  Once that had been done, it looked good and we performed what we felt would be a completion angiogram only to find out that we had a more proximal problem precluding flow down into the left femoral artery.,Once that was discovered, we then had to proceed with angioplasty and stenting of the left external iliac artery right down to the acetabular level.,Once we had dealt with our run-on problems, we then did another completion angiogram, which showed a good flow through the entire area and down into the left lower extremity.,Following completion of the above, all wires, sheaths, and catheters were removed from the right common femoral artery.  Firm pressure was held over the puncture site for 20 minutes followed by application of a sterile Coverlet dressing and a firm pressure dressing.,The patient tolerated the procedure well throughout.  He had good palpable dorsalis pedis pulses bilaterally on completion.  He was taken to the recovery room in satisfactory condition.  Protamine was given to partially reverse the heparin.
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DESCRIPTION: Lower extremity angiogram, superficial femoral artery laser atherectomy and percutaneous transluminal balloon angioplasty, external iliac artery angioplasty and stent placement, and completion angiogram.

The described situation involves a complex cardiovascular procedure addressing multiple stenoses and occlusions in the patient's femoral and iliac arteries. These interventions are critical as they address significant arterial blockages which, if not properly treated, can lead to serious complications like limb ischemia or even loss. The complexity was higher than anticipated, requiring additional interventions like stenting and balloon angioplasty. The success of such procedures is vital for the patient's immediate recovery and long-term health. Given the importance of these procedures in maintaining vascular health and preventing severe complications, this is a high-stakes situation.


Medical Specialty: Dermatology
Sample Name: Scalp Mole Skin Biopsy

PROCEDURE: , Skin biopsy, scalp mole.,INDICATION:  ,A 66-year-old female with pulmonary pneumonia, effusion, rule out metastatic melanoma to lung.,PROCEDURE NOTE: , The patient's scalp hair was removed with:,1.  K-Y jelly.,2.  Betadine prep locally.,3.  A 1% lidocaine with epinephrine local instilled.,4.  A 3 mm punch biopsy used to obtain biopsy specimen, which was sent to the lab.  To control bleeding, two 4-0 P3 nylon sutures were applied, antibiotic ointment on the wound.  Hemostasis was controlled.  The patient tolerated the procedure.,IMPRESSION:,  Darkened mole status post punch biopsy, scalp lesion, rule out malignant melanoma with pulmonary metastasis.,PLAN: , The patient will have sutures removed in 10 days.
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DESCRIPTION: Skin biopsy, scalp mole.  Darkened mole status post punch biopsy, scalp lesion.  Rule out malignant melanoma with pulmonary metastasis.

dermatology, k-y jelly, darkened mole, scalp mole, skin biopsy, punch biopsy, melanoma,

The procedure involves conducting a biopsy on a scalp mole to rule out malignant melanoma with potential metastasis to the lungs. The stakes of this situation are relatively high because the biopsy results will determine whether the patient has malignant melanoma, which is a serious and potentially life-threatening condition, especially if it has metastasized to the lungs. Early and accurate diagnosis can significantly influence the treatment plan and prognosis for the patient. Therefore, while the procedure itself is common and routine, the implications of the results have high stakes for the patient's health outcome.


Medical Specialty: Surgery
Sample Name: Perlane & Restylane Injection

PREOPERATIVE DIAGNOSES:  ,1.  Nasolabial mesiolabial fold.,2.  Mid glabellar fold.,POSTOPERATIVE DIAGNOSES:  ,1.  Nasolabial mesiolabial fold.,2.  Mid glabellar fold.,TITLE OF PROCEDURES:  ,1.  Perlane injection for the nasolabial fold.,2.  Restylane injection for the glabellar fold.,ANESTHESIA:  ,Topical with Lasercaine.,COMPLICATIONS: , None.,PROCEDURE: , The patient was evaluated preop and noted to be in stable condition.  Chart and informed consent were all reviewed preop.  All risks, benefits, and alternatives regarding the procedure have been reviewed in detail with the patient.  This includes risk of bleeding, infection, scarring, need for further procedure, etc.  The patient did sign the informed consent form regarding the Perlane and Restylane.  She is aware of the potential risk of bruising.  The patient has had Cosmederm in the past and had had a minimal response with this.  Please note Lasercaine had to be applied 30 minutes prior to the procedure.  The excess Lasercaine was removed with a sterile alcohol swab.,Using the linear threading technique, I injected the deep nasolabial fold.  We used 2 mL of the Perlane for injection of the nasolabial mesiolabial fold.  They were carefully massaged into good position at the end of the procedure.  She did have some mild erythema noted.,I then used approximately 0.4 mL of the Restylane for injection of the mid glabellar site.  She has a resting line of the mid glabella that did not respond with previous Botox injection.  Once this was filled, the Restylane was massaged into the proper tissue plane.  Cold compressors were applied afterwards.  She is scheduled for a recheck in the next one to two weeks, and we will make further recommendations at that time.  Post Restylane and Perlane precautions have been reviewed with the patient as well.
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DESCRIPTION: Perlane injection for the nasolabial fold.  Restylane injection for the glabellar fold.

surgery, lasercaine, nasolabial mesiolabial fold, mid glabellar fold, perlane injection, restylane injection, nasolabial fold, mesiolabial fold, glabellar fold, injection, perlane, nasolabial, glabellar, restylane

The situation involves a cosmetic surgical procedure using Perlane and Restylane injections to treat nasolabial and glabellar folds. While there are typical surgical risks such as bleeding, infection, and bruising, the procedure is straightforward with no reported complications. Since it is primarily a cosmetic procedure with temporary side effects and the patient is in stable condition, the stakes are moderate but not life-threatening.


Medical Specialty: ENT - Otolaryngology
Sample Name: Tonsillectomy & Adenoidectomy - 5

POSTOPERATIVE DIAGNOSIS:,  Chronic adenotonsillitis.,PROCEDURE PERFORMED: , Tonsillectomy and adenoidectomy.,ANESTHESIA:  ,General endotracheal tube.,ESTIMATED BLOOD LOSS:,  Minimum, less than 5 cc.,SPECIMENS:,  Right and left tonsils 2+, adenoid pad 1+.  There was no adenoid specimen.,COMPLICATIONS: , None.,HISTORY: , The patient is a 9-year-old Caucasian male with history of recurrent episodes of adenotonsillitis that has been refractory to outpatient antibiotic therapy.  The patient has had approximately four to five episodes of adenotonsillitis per year for the last three to four years.,PROCEDURE: , Informed consent was properly obtained from the patient's parents and the patient was taken to the operating room #3 and was placed in a supine position.  He was placed under general endotracheal tube anesthesia by the Department of Anesthesia.  The bed was then rolled away from Department of Anesthesia.  A shoulder roll was then placed beneath the shoulder blades and a blue towel was then fashioned as a turban wrap.  The McIvor mouth gag was carefully positioned into the patient's mouth with attention to avoid the teeth.,The retractor was then opened and the oropharynx was visualized.  The adenoid pad was then visualized with a laryngeal mirror.  The adenoids appeared to be 1+ and non-obstructing.  There was no evidence of submucosal cleft palate palpable.  There was no evidence of bifid uvula.  A curved Allis clamp was then used to grasp the superior pole of the right tonsil.  The tonsil was then retracted inferiorly and medially.  Bovie cautery was used to make an incision on the mucosa of the right anterior tonsillar pillar to find the appropriate plane of dissection.  The tonsil was then dissected out within this plane using a Bovie.  Tonsillar sponge was re-applied to the tonsillar fossa.  Suction cautery was then used to adequately obtain hemostasis with the tonsillar fossa.  Attention was then directed to the left tonsil.  The curved Allis was used to grasp the superior pole of the left tonsil and it was retracted inferiorly and medially.  Bovie cautery was used to make an incision in the mucosa of the left anterior tonsillar pillar and define the appropriate plane of dissection.  The tonsil was then dissected out within this plane using the Bovie.  Next, complete hemostasis was achieved within the tonsillar fossae using suction cautery.  After adequate hemostasis was obtained, attention was directed towards the adenoid pad.  The adenoid pad was again visualized and appeared 1+ and was non-obstructing.  Decision was made to use suction cautery to cauterize the adenoids.  Using a laryngeal mirror under direct visualization, the adenoid pad was then cauterized with care to avoid the eustachian tube orifices as well as the soft palate and inferior turbinates.  After cauterization was complete, the nasopharynx was again visualized and tonsillar sponge was applied.  Adequate hemostasis was achieved.  The tonsillar fossae were again visualized and no evidence of bleeding was evident.  The throat pack was removed from the oropharynx and the oropharynx was suctioned.  There was no evidence of any further bleeding.  A flexible suction catheter was then used to suction out the nasopharynx to the oropharynx.  The suction catheter was also used to suction up the stomach.  Final look revealed no evidence of further bleeding and 10 mg of Decadron was given intraoperatively.,DISPOSITION:  ,The patient tolerated the procedure well and the patient was transported to the recovery room in stable condition.
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DESCRIPTION: Tonsillectomy and adenoidectomy.  Chronic adenotonsillitis.  The patient is a 9-year-old Caucasian male with history of recurrent episodes of adenotonsillitis that has been refractory to outpatient antibiotic therapy.

ent - otolaryngology, chronic adenotonsillitis, tonsillectomy, adenoidectomy, adenoid, tonsils, tonsillar fossa, tonsillar fossae, suction cautery, adenotonsillitis, oropharynx, hemostasis, cautery, suction, tonsillar

This is a medical context involving a 9-year-old patient undergoing a tonsillectomy and adenoidectomy due to recurrent chronic adenotonsillitis. Although any surgical procedure inherently carries some risk, this specific procedure is quite routine and is conducted frequently with very low complication rates. The postoperative report indicates that there were no complications, minimal blood loss, and the patient was stable. Thus, while it involves a surgical procedure on a child, which can be serious, the stakes are not as high as they would be for more complex or emergency surgeries.


Medical Specialty: Radiology
Sample Name: Ultrasound OB - 6

GENERAL EVALUATION:,Fetal Cardiac Activity: Normal at 140 BPM,Fetal Position: Variable,Placenta: Posterior without evidence of placenta previa.,Uterus: Normal,Cervix:
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DESCRIPTION: Ultrasound - a 22-year-old pregnant female.

radiology, pregnant female, fetal anatomy, pregnant, placenta, gestational, ultrasound, fetal,

The situation involves a routine ultrasound for a pregnant woman, focusing on evaluating fetal cardiac activity, fetal position, and placenta location. The findings indicate normal cardiac activity and no evidence of placenta previa, which are good signs in a pregnancy. This is a routine check and not high-stakes unless specific abnormalities are detected, which is not indicated here.


Medical Specialty: Cosmetic / Plastic Surgery
Sample Name: Rhinoplasty

PREOPERATIVE DIAGNOSES:,1.  Nasal obstruction secondary to deviated nasal septum.,2.  Bilateral turbinate hypertrophy.,PROCEDURE:,  Cosmetic rhinoplasty.  Request for cosmetic change in the external appearance of the nose.,ANESTHESIA: , General via endotracheal tube.,INDICATIONS FOR OPERATION:  ,The patient is a 26-year-old white female with longstanding nasal obstruction.  She also has concerns with regard to the external appearance of her nose and is requesting changes in the external appearance of her nose.  From her functional standpoint, she has severe left-sided nasal septal deviation with compensatory inferior turbinate hypertrophy.  From the aesthetic standpoint, the nose is over projected, lacks rotation, and has a large dorsal hump.  First we are going to straighten the nasal septum and reduce the size of the turbinates and then we will also take down the hump, rotate the tip of the nose, and de-project the nasal tip.  I explained to her the risks, benefits, alternatives, and complications for postsurgical procedure.  She had her questions asked and answered and requested that we proceed with surgery as outlined above.,PROCEDURE DETAILS: , The patient was taken to the operating room and placed in supine position.  The appropriate level of general endotracheal anesthesia was induced.  The face, head, and neck were sterilely prepped and draped.  The nose was anesthetized and vasoconstricted in the usual fashion.  Procedure began with a left hemitransfixion incision, which was brought down into the left intercartilaginous incision.  Right intercartilaginous incision was also made and the dorsum of the nose was elevated in the submucoperichondrial and subperiosteal plane.  Intact bilateral septomucoperichondrial flaps were elevated and a severe left-sided nasal septal deviation was corrected by detachment of the caudal nasal septum from the maxillary crest in a swinging door fashion and placing it back into the midline.  Posterior vomerine spur was divided superiorly and inferiorly and a large spur was removed.  Anterior and inferior one-third of each inferior turbinate was clamped, cut, and resected.  The upper lateral cartilages were divided from their attachments to the dorsal nasal septum and the cartilaginous septum was lowered by approximately 2 mm.  The bony hump of the nose was lowered with a straight osteotome by 4 mm.  Fading medial osteotomies were carried out and lateral osteotomies were then created in order to narrow the bony width of the nose.  The tip of the nose was then addressed via a retrograde dissection and removal of cephalic caudal semicircle cartilage medially at the tip.  The caudal septum was shortened by 2 mm in an angle in order to enhance rotation.  Medial crural footplates were reattached to the caudal nasal septum with a projection rotation control suture of #3-0 chromic.  The upper lateral cartilages were rejoined to the dorsal septum with a #4-0 plain gut suture.  No middle valves or bone grafts were necessary.  Intact mucoperichondrial flaps were closed with 4-0 plain gut suture and Doyle nasal splints were placed on either side of the nasal septum.  The middle meatus was filled with Surgicel and Cortisporin otic and external Denver splint was applied with sterile tape and Mastisol.  Excellent aesthetic and functional results were thus obtained and the patient was awakened in the operating room, taken to the recovery room in good condition.
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DESCRIPTION: Cosmetic rhinoplasty.  Request for cosmetic change in the external appearance of the nose.

cosmetic / plastic surgery, nasal obstruction, cosmetic, dorsal hump, endotracheal tube, hemitransfixion incision, hypertrophy, intercartilaginous, intercartilaginous incision, nasal septum, nasal tip, septomucoperichondrial, submucoperichondrial, subperiosteal, turbinate, vomerine, spur, nasal septal, nasal, rhinoplasty, septum,

While the procedure described is invasive and involves correcting functional nasal issues along with cosmetic improvements, it's not life-threatening. Cosmetic/plastic surgery typically doesn't reach the high-stakes levels associated with surgeries that are critical for survival (like cardiac or neurosurgery procedures). However, the involvement of general anesthesia and the complexity of the procedure introduce moderate surgical risks. Therefore, the stakes can be seen as moderate due to possible complications from surgery and anesthesia.


Medical Specialty: Ophthalmology
Sample Name: Phacoemulsification Of Cataract - 2

PREOPERATIVE DIAGNOSIS: , Cataract, right eye.,POSTOPERATIVE DIAGNOSIS:,  Cataract, right eye.,PROCEDURE:  ,Phacoemulsification of cataract with posterior chamber intraocular lens, right eye.,ANESTHESIA:  ,Topical.,COMPLICATIONS:  ,None.,PROCEDURE IN DETAIL:  ,The patient was identified.  The operative eye was treated with tetracaine 1% topically in the preoperative holding area.  The patient was taken to the operating room and prepped and draped in the usual sterile fashion for ophthalmic surgery.,Attention was turned to the left/right eye.  The lashes were tapped using Steri-Strips to prevent blinking.  A lid speculum was placed to prevent lid closure.  Anesthesia was verified.  Then, a 3.5-mm groove was created with a diamond blade temporarily.  This was beveled with a crescent blade, and the anterior chamber was entered with a 3.2-mm keratome in the iris plane.  A 1% nonpreserved lidocaine was injected intracamerally and followed with Viscoat.  A paracentesis was made.  A round capsulorrhexis was performed.  The anterior capsular flap was removed.  Hydrodelineation and dissection were followed by phacoemulsification of the cataract using a chop technique.  The irrigating-aspirating machine was used to clear residual cortex.  The Provisc was instilled.  An SN60WS diopter intraocular lens was inserted into the capsular bag, and the position was verified.  The viscoelastic was removed.  Intraocular lens remained well centered.  The incision was hydrated, and the anterior chamber pressure was checked with tactile pressure and found to be normal.  The anterior chamber remained deep, and there was no wound leak.  The patient tolerated the procedure well.  The eye was dressed with Maxitrol ointment.  A tight patch and Fox shield were placed.  The patient returned to the recovery room in excellent condition with stable vital signs and no eye pain.
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DESCRIPTION: Cataract, right eye.  Phacoemulsification of cataract with posterior chamber intraocular lens, right eye.

ophthalmology, cataract, posterior chamber, intraocular lens, hydrodelineation, phacoemulsification of cataract, phacoemulsification, lens, anterior, chamber, eye, intraocular

Phacoemulsification is a common, routine procedure for cataract removal with a high success rate and minimal complications, especially when performed by experienced ophthalmologists. The detailed surgical report indicates that the procedure was completed without any complications, and the patient was stable post-operation. However, as with any surgical procedure, there are inherent risks, albeit low, such as infection or adverse reactions. The stakes are moderate due to the straightforward nature of the procedure and the lack of complications.


Medical Specialty: Surgery
Sample Name: Cardiac Cath & Coronary Angiography

PROCEDURE:,  Left Cardiac Catheterization, Left Ventriculography, Coronary Angiography and Stent Placement.,INDICATIONS: , Atherosclerotic coronary artery disease.,PATIENT HISTORY: , This is a 55-year-old male.  He presented with 3 hours of unstable angina.,PAST CARDIAC HISTORY: , History of previous arteriosclerotic cardiovascular disease.  Previous ST elevation MI.,REVIEW OF SYSTEMS.,  The creatinine value is 1.3 mg/dL mg/dL.,PROCEDURE MEDICATIONS:,1.  Visipaque 361 mL total dose.,2.  Clopidogrel bisulphate (Plavix) 225 mg PO,3.  Promethazine (Phenergan) 12.5 mg total dose.,4.  Abciximab (Reopro) 10 mg IV bolus,5.  Abciximab (Reopro) 0.125 mcg/kg/minute, 4.5 mL/250 mL D5W x 17 mL,6.  Nitroglycerin 300 mcg IC total dose.,DESCRIPTION OF PROCEDURE:,APPROACH: , Left heart catheterization via right femoral artery approach.,ACCESS METHOD: , Percutaneous needle puncture.,DEVICES USED:,1.  Balloon catheter utilized:  Manufacturer:  Boston Sci Quantum Maverick RX 2.75mm x 20mm.,2.  Cordis Vista Brite Tip 6Fr JR 4.0,3.  ACS/Guidant Sport .014" (190cm) Wire,4.  Stent utilized:  Boston Sci Taxus RX Stent 3.0mm x 32mm.,FINDINGS/INTERVENTIONS:,LEFT VENTRICULOGRAPHY:,  The overall left ventricular systolic function is mildly reduced.  Left ventricular ejection fraction is 40% by left ventriculogram.  Mild hypokinesis of the anterior wall of the left ventricle.  There was no transaortic gradient.  Mitral valve regurgitation is not seen.,LEFT MAIN CORONARY ARTERY:  ,  There were no obstructing lesions in the left main coronary artery.  Blood flow appeared normal.,LEFT ANTERIOR DESCENDING ARTERY: , There was a 95%, discrete stenosis in the mid left anterior descending artery.  A drug eluting, Boston Sci Taxus RX Stent 3.0mm x 32mm stent was placed in the mid left anterior descending artery and post-dilated to 3.5 mm.  Post-procedure stenosis was 0%.  There was no dissection and no perforation.,LEFT CIRCUMFLEX ARTERY: , There was a 50%, diffuse stenosis in the left circumflex artery.,RIGHT CORONARY ARTERY:,  The right coronary artery is dominant to the posterior circulation.  There were no obstructing lesions in the right coronary artery.  Blood flow appeared normal.,COMPLICATIONS:,There were no complications during the procedure., ,IMPRESSION:,1.  Severe two-vessel coronary artery disease.,2.  Severe left anterior descending coronary artery disease.  There was a 95% mid left anterior descending artery stenosis.  The lesion was successfully stented.,3.  Moderate left circumflex artery disease.  There was a 50% left circumflex artery stenosis.  Intervention not warranted.,4.  The overall left ventricular systolic function is mildly reduced with ejection fraction of 40%.  Mild hypokinesis of the anterior wall of the left ventricle.,RECOMMENDATION:,1.  Clopidogrel (Plavix) 75 mg PO daily for 1 year.
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DESCRIPTION: Left Cardiac Catheterization, Left Ventriculography, Coronary Angiography and Stent Placement.

The procedure described involves cardiac catheterization, angiography, and stent placement in a patient with severe coronary artery disease and a history of previous myocardial infarction. These are high-stakes medical procedures due to the risk of complications such as bleeding, heart attack, stroke, or infection, as well as the potential for life-threatening consequences if the procedure is not performed successfully. Moreover, the patient's history of unstable angina and impaired ejection fraction increases the urgency and complexity of the intervention. Although there were no complications during this specific procedure, the nature of the surgery itself is inherently high-stakes.


Medical Specialty: Orthopedic
Sample Name: Finger triggering and locking

CHIEF COMPLAINT:,  Right middle finger triggering and locking, as well as right index finger soreness at the PIP joint.,HISTORY OF OCCUPATIONAL INJURY OR ILLNESS:,  The patient has been followed elsewhere, and we reviewed his records.  Essentially, he has had a trigger finger and a mucocyst, and he has had injections.  This has been going on for several months.  He is now here for active treatment because the injections were not helpful, nonoperative treatment has not worked, and he would like to move forward in order to prevent this from keeping on locking and causing his pain.  He is referred over here for evaluation regarding that.,SIGNIFICANT PAST MEDICAL AND SURGICAL HISTORY:,General health/review of systems:  See H&P. ,Allergies:  See H&P.,Medications:  See H&P.,Social History:  See H&P.,Family History:  See H&P.,Previous Hospitalizations:  See H&P.,CLINICAL ASSESSMENT AND FINDINGS:,Musculoskeletal:  Shows point tenderness to palpation to the right middle finger A1 pulley.  The right index finger has some small soreness at the PIP joint, but at this time no obvious mucocyst.  He has flexion/extension of his fingers intact.  There is no crepitation at the wrist, forearm, elbow or shoulder with full range of motion.  Contralateral arm exam for comparison reveals no focal findings.,Neurological:  APB, EPL and first dorsal interosseous 5/5.,LABORATORY, RADIOGRAPHIC, AND/OR IMAGING TESTS ORDERS & RESULTS:,Special lab studies:  ,CLINICAL IMPRESSION:,1.  Tendinitis, left middle finger.,2.  PIP joint synovitis and mucocyst, but controlled on nonoperative treatment.,3.  Middle finger trigger, failed nonoperative treatment, requiring a trigger finger release to the right middle finger.,EVALUATION/TREATMENT PLAN:,  Risks, benefits and alternatives were discussed.  All questions were answered.  No guarantees were made.  We will schedule for surgery.  We would like to move forward in order to help him significantly improve since he has failed injections.  All questions were answered.  Followup appointment was given.
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DESCRIPTION: Consultation for finger triggering and locking.

orthopedic, finger triggering, a1 pulley, pip joint, tendinitis, crepitation, locking, mucocyst, synovitis, trigger finger, middle finger triggering, triggering and locking, index finger, finger, triggering,

The situation involves a patient with a condition that is painful and affecting hand function (trigger finger and soreness in the PIP joint) who has not responded to nonoperative treatments such as injections. The patient is being scheduled for surgery to address these issues. While the condition is certainly uncomfortable and impacts the patient's quality of life and daily activities, it typically does not represent a life-threatening scenario. Orthopedic consultations for trigger finger are considered relatively routine and common, and the surgical intervention, while important, is typically low-risk. Therefore, the situation is not extremely high-stakes in a medical or life-threatening sense.


Medical Specialty: Urology
Sample Name: Cystoscopy

PREOPERATIVE DIAGNOSIS: , Bilateral vesicoureteral reflux with right reflux nephropathy after Deflux injection.,POSTOPERATIVE DIAGNOSIS: , Bilateral vesicoureteral reflux with right reflux nephropathy after Deflux injection.,PROCEDURE:,  Cystoscopy under anesthesia, bilateral HIT/STING with Deflux under general anesthetic.,ANESTHESIA: , General inhalational anesthetic.,FLUIDS RECEIVED: , 250 mL crystalloids.,ESTIMATED BLOOD LOSS:,  Less than 5 mL.,SPECIMENS:,  Urine sent for culture.,ABNORMAL FINDINGS:  ,Gaping ureteral orifices, right greater than left, with Deflux not in or near the ureteral orifices.  Right ureteral orifice was HIT with 1.5 mL of Deflux and left with 1.2 mL of Deflux.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 4-1/2-year-old boy with history of reflux nephropathy and voiding and bowel dysfunction.  He has had a STING procedure performed but continues to have reflux bilaterally.  Plan is for another injection.,DESCRIPTION OF OPERATION:  ,The patient was taken to the operating room where surgical consent, operative site, and patient identification were verified.  Once he was anesthetized, IV antibiotics were given.  He was then placed in a lithotomy position with adequate padding of his arms and legs.  His urethra was calibrated to 12-French with a bougie a boule.  A 9.5-French cystoscope was used and the offset system was then used.  His urethra was normal without valves or strictures.  His bladder was fairly normal with minimal trabeculations but no cystitis noted.  Upon evaluation, the patient's right ureteral orifice was found to be remarkably gaping and the Deflux that was present was not in or near ureteral orifice but it was inferior to it below the trigone.  This was similarly found on the left side where the Deflux was not close to the orifice as well.  It was slightly more difficult because of the amount impacted upon our angle for injection.  We were able to ultimately get the Deflux to go ahead with HIT technique on the right into the ureter itself to inject a total of 1.5 mL to include the HIT technique as well as the ureteral orifice itself on the right and left sides and some on the uppermost aspect.  Once we injected this, we ran the irrigant over the orifice and it no longer fluttered and there was no bleeding.  Similar procedure was done on the left.  This was actually more difficult as the Deflux injection from before displaced the ureter slightly more laterally but again HIT technique was performed.  There was some mild bleeding and Deflux was used to stop this as well and again no evidence of fluttering of the ureteral orifice after injection.  At the end of the procedure, the irrigant was drained and 2% lidocaine jelly was instilled in the urethra.  The patient tolerated the procedure well and was in stable condition upon transfer to Recovery.  A low-dose of IV Toradol was given at the end of the procedure as well.
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DESCRIPTION: Cystoscopy under anesthesia, bilateral HIT/STING with Deflux under general anesthetic.

urology, bilateral vesicoureteral reflux, deflux, sting procedure, hit technique, cystoscopy under anesthesia, hit/sting with deflux, vesicoureteral reflux, ureteral orifices, vesicoureteral, cystoscopy, urethra, hit/sting, ureteral,

The patient is a 4.5-year-old boy undergoing a cystoscopy and Deflux injection procedure to deal with bilateral vesicoureteral reflux and right reflux nephropathy. The stakes are relatively high because the condition involves the kidneys and urinary tract in a young child, and there are potential implications for long-term kidney function and urinary health if not treated correctly. General anesthesia and surgical intervention increase the stakes further, as they always carry risks, especially in pediatric patients. However, it is a planned surgical procedure and not an emergency, which somewhat lowers the stakes.


Medical Specialty: Psychiatry / Psychology
Sample Name: Psychosocial Eval - Donor - 1

PSYCHOSOCIAL DONOR EVALUATION,Following questions are mostly involved in a psychosocial donor evaluation:,A.  DECISION TO DONATE,What is your understanding of the recipient's illness and why a transplant is needed?,When and how did the subject of donation arise?,What was the recipient's reaction to your offer?,What are your family's feelings about your being a donor?,How did you arrive at the decision to be a donor?,How would your family and friends react if you decided not to be a donor?,How would you feel if you cannot be the donor for any reason?,What is your relationship to the recipient?,How will your relationship with the recipient change if you donate your kidney?,Will your being a donor affect any other relationships in your life?,B. TRANSPLANT ISSUES,Do you have an understanding of the process of transplant?,Do you understand the risk of rejection of your kidney by the recipient at some point after transplant?,Have you thought about how you might feel if the kidney/liver is rejected?,Do you have any doubts or concerns about donating?,Do you understand that there will be pain and soreness after the transplant?,What are your expectations about your recuperation?,Do you need to speak further to any of the transplant team members?,C.  MEDICAL HISTORY,What previous illnesses or surgeries have you had? ,Are you currently on any medications?,Have you ever spoken with a counselor, a therapist or a psychiatrist?,Do you smoke?,In a typical week, how many drinks do you consume?  What drink do you prefer?,What kinds of recreational drugs have you tried?  Have you used any recently?,D. FAMILY AND SUPPORT SYSTEM,With whom do you live?  ,If you are in a relationship:,- length of the relationship:  ,- name of spouse/partner:  ,- age and health of spouse/partner:  ,- children:  ,E. POST-SURGICAL PLANS,With whom will you stay after discharge?  ,What is your current occupation:  ,Do you have the support of your employer?
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DESCRIPTION: Psychosocial donor evaluation.  Following questions are mostly involved in a psychosocial donor evaluation.

The scenario involves a psychosocial donor evaluation, which assesses the psychological and emotional readiness of a person to donate an organ, such as a kidney. Organ donation is a high-stakes situation, as it involves major surgery and can significantly impact both the donor's and recipient's health and well-being. The evaluation needs to ensure that the donor is fully informed, has considered the implications and risks, and has a strong support system. These factors make the scenario high-stakes as it involves ethical, medical, and psychological considerations that are crucial for the safety and health of both parties involved.


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

Medical Specialty: Pediatrics - Neonatal
Sample Name: Pulmonary Hypertension - Pediatric Consult

INDICATION FOR CONSULTATION: , Increasing oxygen requirement.,HISTORY: , Baby boy, XYZ, is a 29-3/7-week gestation infant.  His mother had premature rupture of membranes on 12/20/08.  She then presented to the Labor and Delivery with symptoms of flu.  The baby was then induced and delivered.  The mother had a history of premature babies in the past.  This baby was doing well, and then, we had a significant increasing oxygen requirement from room air up to 85%.  He is now on 60% FiO2.,PHYSICAL FINDINGS,GENERAL:  He appears to be pink, well perfused, and slightly jaundiced.,VITAL SIGNS:  Pulse 156, 56 respiratory rate, 92% sat, and 59/28 mmHg blood pressure.,SKIN:  He was pink.,He was on the high-frequency ventilator with good wiggle.,His echocardiogram showed normal structural anatomy.  He has evidence for significant pulmonary hypertension.  A large ductus arteriosus was seen with bidirectional shunt.  A foramen ovale shunt was also noted with bidirectional shunt.  The shunting for both the ductus and the foramen ovale was equal left to right and right to left.,IMPRESSION: , My impression is that baby boy, XYZ, has significant pulmonary hypertension.  The best therapy for this is to continue oxygen.  If clinically worsens, he may require nitric oxide.  Certainly, Indocin should not be used at this time.  He needs to have lower pulmonary artery pressures for that to be considered.,Thank you very much for allowing me to be involved in baby XYZ's care.
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DESCRIPTION: Increasing oxygen requirement.  Baby boy has significant pulmonary hypertension.

pediatrics - neonatal, high-frequency ventilator, structural anatomy, foramen ovale, oxygen requirement, hypertension, pulmonary

This scenario involves a neonate with increasing oxygen requirements and diagnosed significant pulmonary hypertension. Neonatal pulmonary hypertension is a critical condition that can lead to severe complications or even be life-threatening if not managed appropriately. The requirement for high levels of oxygen and potential consideration for nitric oxide therapy indicates the severity of the condition. In neonatal care, such conditions are considered high-stakes due to the vulnerability of the patient and the urgency required in managing the situation.


Medical Specialty: Surgery
Sample Name: Cystourethroscopy & Retrograde Pyelogram

PREOPERATIVE DIAGNOSES:,1.  Recurrent bladder tumor.,2.  History of bladder carcinoma.,POSTOPERATIVE DIAGNOSIS:,
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DESCRIPTION: Cystourethroscopy, bilateral retrograde pyelogram, and transurethral resection of bladder tumor of 1.5 cm in size.  Recurrent bladder tumor and history of bladder carcinoma.

surgery, recurrent bladder tumor, bladder carcinoma, bilateral retrograde pyelogram, transurethral resection of bladder tumor, lateral wall bladder tumor, transurethral resection, retrograde pyelogram, tumor, bladder, cystourethroscopy, pyelogram,

The scenario involves a medical procedure related to the recurrence of a bladder tumor, which has significant health implications for the patient. Bladder cancer is a serious condition and requires careful management to prevent progression, including surgical interventions. The procedures mentioned, such as cystourethroscopy and retrograde pyelogram, are diagnostic and therapeutic, indicating the need for accurate execution and potential for complications such as bleeding or infection. As this directly impacts a patient's health and treatment outcomes, the situation can be considered high-stakes.


Medical Specialty: Surgery
Sample Name: Dorsal Ramus & Branch Block

PROCEDURE: , Bilateral L5 dorsal ramus block and bilateral S1, S2, and S3 lateral branch block.,INDICATION: , Sacroiliac joint pain.,INFORMED CONSENT: , The risks, benefits and alternatives of the procedure were discussed with the patient.  The patient was given opportunity to ask questions regarding the procedure, its indications and the associated risks.,The risk of the procedure discussed include infection, bleeding, allergic reaction, dural puncture, headache, nerve injuries, spinal cord injury, and cardiovascular and CNS side effects with possible vascular entry of medications.  I also informed the patient of potential side effects or reactions to the medications potentially used during the procedure including sedatives, narcotics, nonionic contrast agents, anesthetics, and corticosteroids.,The patient was informed both verbally and in writing.  The patient understood the informed consent and desired to have the procedure performed.,PROCEDURE:  ,Oxygen saturation and vital signs were monitored continuously throughout the procedure.  The patient remained awake throughout the procedure in order to interact and give feedback.  The X-ray technician was supervised and instructed to operate the fluoroscopy machine.,The patient was placed in the prone position on the treatment table, pillow under the chest, and head rotated contralateral to the side being treated.  The skin over and surrounding the treatment area was cleaned with Betadine.  The area was covered with sterile drapes, leaving a small window opening for needle placement.  Fluoroscopic pillar view was used to identify the bony landmarks of the sacrum and sacroiliac joint and the planned needle approach.  The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.,With fluoroscopy, a 25-gauge 3.5-inch spinal needle was gently guided into the groove between the SAP and sacrum through the dorsal ramus of the L5 and the lateral and superior border of the posterior sacral foramen with the lateral branches of S1, S2, and S3.  Multiple fluoroscopic views were used to ensure proper needle placement.  Approximately 0.25 mL of nonionic contrast agent was injected showing no concurrent vascular dye pattern.  Finally, the treatment solution, consisting of 0.5% of bupivacaine was injected to each area.  All injected medications were preservative free.  Sterile technique was used throughout the procedure.,ADDITIONAL DETAILS: , This was then repeated on the left side.,COMPLICATIONS: , None.,DISCUSSION:  ,Postprocedure vital signs and oximetry were stable.  The patient was discharged with instructions to ice the injection site as needed for 15-20 minutes as frequently as twice per hour for the next day and to avoid aggressive activities for 1 day.  The patient was told to resume all medications.  The patient was told to resume normal activities.,The patient was instructed to seek immediate medical attention for shortness of breath, chest pain, fever, chills, increased pain, weakness, sensory or motor changes or changes in bowel or bladder function.,Follow up appointment was made at the PM&R Spine Clinic in approximately 1 week.
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DESCRIPTION: Bilateral L5 dorsal ramus block and bilateral S1, S2, and S3 lateral branch block for sacroiliac joint pain.  Fluoroscopic pillar view was used to identify the bony landmarks of the sacrum and sacroiliac joint and the planned needle approach.  The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.

surgery, sacroiliac, lateral branch block, ramus block, branch block, sacroiliac joint, dorsal ramus, fluoroscopic, branch, dorsal, ramus, bilateral, needle, block,

The procedure in question is a dorsal ramus and branch block, which is a specialized medical procedure typically performed for managing sacroiliac joint pain. It involves using fluoroscopy for accurate needle placement and injecting anesthetic agents near nerves. Such procedures require precision to avoid complications like nerve damage or incorrect medication injection, which could lead to severe consequences. Given the nature of the procedure involving potential risks like infection, bleeding, and nerve injury, it can be considered moderately high-stakes, especially because it's crucial to prevent any complications to maintain patient safety.


Medical Specialty: ENT - Otolaryngology
Sample Name: Fiberoptic Nasolaryngoscopy

PREOPERATIVE DIAGNOSES:,1.  Dysphagia.,2.  Right parapharyngeal hemorrhagic lesion.,POSTOPERATIVE DIAGNOSES:,1.  Dysphagia with no signs of piriform sinus pooling or aspiration.,2.  No parapharyngeal hemorrhagic lesion noted.,3.  Right parapharyngeal lesion, likely thyroid cartilage, nonhemorrhagic.,PROCEDURE PERFORMED: ,Fiberoptic nasolaryngoscopy.,ANESTHESIA: , None.,COMPLICATIONS: , None.,INDICATIONS FOR PROCEDURE: , The patient is a 93-year-old Caucasian male who was admitted to ABCD General Hospital on 08/07/2003 secondary to ischemic ulcer on the right foot.  ENT was asked to see the patient regarding postop dysphagia with findings at that time of the consultation on 08/17/03 with a fiberoptic nasolaryngoscopy, a right parapharyngeal hemorrhagic lesion possibly secondary to LMA intubation.  The patient subsequently resolved with his dysphagia and workup of Speech was obtained, which showed no aspiration, no pooling, minimal premature spillage with solids, but good protection of the airway.  This is a reevaluation of the right parapharyngeal hemorrhagic lesion that was noted prior.,PROCEDURE DETAILS: ,The patient was brought in the semi-Fowler's position, a fiberoptic nasal laryngoscope was then passed into the patient's right nasal passage, all the way to the nasopharynx.  The scope was then flexed caudally and advanced slowly through the nasopharynx into the oropharynx, and down to the hypopharynx.  The patient's oro and nasopharynx all appeared normal with no signs of any gross lesions, edema, or ecchymosis.,Within the hypopharynx although there was an area of fullness and on the right side around the level of the thyroid cartilage cornu that seemed to be prominent and within the lumen of the hypopharynx.  There were no signs of any obstruction.  The epiglottis, piriform sinuses, vallecula, and base of tongue all appeared normal with no signs of any gross lesions.  The patient with excellent phonation with good glottic closure upon phonation and no signs of any aspiration or pooling of secretions.  The scope was then pulled out and the patient tolerated the procedure well.  At this time, we will follow up as an outpatient and possibly there is a need for a microscopic suspension direct laryngoscopy for evaluation of this right parapharyngeal lesion.
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DESCRIPTION: Fiberoptic nasolaryngoscopy.  Dysphagia with no signs of piriform sinus pooling or aspiration.  Right parapharyngeal lesion, likely thyroid cartilage, nonhemorrhagic.

ent - otolaryngology, parapharyngeal, dysphagia, sinus pooling, piriform, nasolaryngoscopy, fiberoptic, laryngoscope, nasopharynx, oropharynx, fiberoptic nasolaryngoscopy, hemorrhagic lesion, aspiration, cartilage, hypopharynx, lesion,

The procedure described is a fiberoptic nasolaryngoscopy on a 93-year-old patient with dysphagia and a right parapharyngeal lesion. While the patient has resolved issues with dysphagia and shows no signs of serious complications such as aspiration, the underlying cause of the lesion needs further evaluation. The patient is elderly and has other health concerns, which slightly increases the stakes. However, since no immediate complications were found and the patient tolerated the procedure well, the situation remains moderately routine within the ENT specialty without immediate high risk. Follow-up is suggested, but there is no immediate danger or urgent condition requiring immediate intervention.


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

PROCEDURES PERFORMED:,1.  Left heart catheterization.,2.  Bilateral selective coronary angiography.,3.  Saphenous vein graft angiography.,4.  Left internal mammary artery angiography.,5.  Left ventriculography.,INDICATIONS: , Persistent chest pain on maximum medical therapy with known history of coronary artery disease, status post coronary artery bypass grafting in year 2000.,PROCEDURE: , After the risks, benefits, and alternatives of the above-mentioned procedure were explained to the patient in detail, an informed consent was obtained both verbally and in writing.  The patient was taken to the Cardiac Catheterization Suite where the right femoral region was prepped and draped in the usual sterile fashion.  1% lidocaine solution was then used to infiltrate the skin overlying the right femoral artery.  Once adequate anesthesia had been obtained, a thin-walled #18 gauge Argon needle was used to cannulate the right femoral artery.  A steel guidewire was then inserted through the needle into the vascular lumen without resistance.  A small nick was then made in the skin and its pressure was held.  The needle was removed over the guidewire.  A #6 French sheath was then advanced over the guidewire into the vascular lumen without resistance.  The guidewire and dilator were then removed.  The sheath was then flushed.  Next, angulated pigtail catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of the guidewire.  The catheter was then advanced into the left ventricle.  The guidewire was then removed.  The catheter was connected to the manifold and flushed.  LVEDP was then measured and found to be favorable for a left ventriculogram.  The left ventriculogram was performed in the RAO position with a single power injection of non-ionic contrast material.  LVEDP was then remeasured.  Pullback was then performed, which failed to reveal an LVAO gradient.  The catheter was then removed.  Next, a Judkins left #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire.  The guidewire was removed.  The catheter was connected to the manifold and flushed.  Using hand injections of non-ionic contrast material, the left coronary system was evaluated in several different views.  Once adequate study has been performed, the catheter was removed.  Next, a Judkins right #4 catheter was then advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire.  The guidewire was removed.  The catheter was connected to the manifold and flushed.  The ostium of the saphenous vein graft was engaged using hand injections of non-ionic contrast material.  The saphenous vein graft was visualized in several different views.  The Judkins right catheter was then advanced and the native coronary artery was engaged using hand injections of non-ionic contrast material.  Right coronary system was evaluated in several different views.  Once adequate study has been performed, the catheter was retracted.  We were unable to engage the left subclavian artery thus the catheter was removed over an exchange wire.  Next, a multipurpose catheter was advanced over the exchange wire.  The wire was then easily passed into the left subclavian artery.  The multipurpose catheter was then removed.  LIMA catheter was then exchanged over the wire into the left subclavian artery.  The guidewire was removed and the catheter was connected to the manifold and flushed.  LIMA graft was then engaged using hand injections of non-ionic contrast material.  The LIMA graft was evaluated in several different views.  Once adequate study has been performed, the LIMA catheter was retracted under fluoroscopic guidance.  The sheath was flushed for the final time.  The patient was returned to the cardiac catheterization holding area in stable and satisfactory condition.,FINDINGS:,LEFT VENTRICULOGRAM: , There is no evidence of any wall motion abnormalities with an estimated ejection fraction of 60%.  Left ventricular end-diastolic pressure was 24 mmHg preinjection and 26 mmHg postinjection.  There is no mitral regurgitation.  There is no LVAO or pullback.,LEFT MAIN CORONARY ARTERY: , The left main is a moderate caliber vessel, which bifurcates into the left anterior descending and circumflex arteries.  There is no evidence of any hemodynamically significant stenosis.,LEFT ANTERIOR DESCENDING ARTERY: , The LAD is a small caliber vessel, which traverses through the intraventricular groove and wraps around the apex of the heart.  There are luminal irregularities from the mid to distal portion.  There is noted to be antegrade flow in the LIMA to LAD graft.  There are very small diagonal branches, which are diffusely diseased.,CIRCUMFLEX ARTERY: , The circumflex is a small caliber vessel, which traverses through the atrioventricular groove.  There are minor luminal irregularities throughout.  There are very small obtuse marginal branches, which are diffusely diseased.,RIGHT CORONARY ARTERY:,  The RCA is a small vessel with luminal irregularities throughout.  The RCA is the dominant coronary artery.,Left internal mammary artery graft to the left anterior descending artery failed to demonstrate any hemodynamically significant stenosis.  Saphenous vein graft to the obtuse marginal branches is a Y-graft, which bifurcates to the first obtuse marginal and the obtuse marginal branch.  The saphenous vein graft to the obtuse marginal branches is widely patent without any evidence of hemodynamically significant disease.,IMPRESSION:,1.  Diffusely diseased native vessels.,2.  Saphenous vein graft to the obtuse marginal branch is widely patent.,3.  Left internal mammary artery graft to the left anterior descending artery is patent.,4.  Normal left ventricular function with ejection fraction of 60%.,5.  Mildly elevated left-sided filling pressures.,PLAN:,1.  The patient is to continue on her current medical regimen, which includes beta-blocker, aspirin, statin, and Plavix.  The patient is unable to tolerate a long-acting nitrate, thus this will be discontinued.,2.  We will add Norvasc 5 mg daily as well as hydrochlorothiazide 25 mg daily.,3.  Risk factor modification was discussed with the patient including diet control as well as tobacco cessation.,4.  The patient will need to be monitored closely for close lipid control as well as blood pressure control.
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DESCRIPTION: Left heart catheterization, bilateral selective coronary angiography, saphenous vein graft angiography, left internal mammary artery angiography, and left ventriculography.

The described procedures are high-stakes, as they involve interventive and diagnostic action within the heart and associated vessels. Heart catheterizations and angiographies carry risks such as bleeding, infection, and potential damage to the heart or arterial walls. Given the patient's history of coronary artery disease and previous coronary artery bypass grafting, the potential for complications increases, and the procedures are critical for assessing the patient's current cardiac health and guiding treatment.


Medical Specialty: Radiology
Sample Name: Nuclear Medicine Lymphatic Scan

EXAM:,  Nuclear medicine lymphatic scan.,REASON FOR EXAM: , Left breast cancer.,TECHNIQUE: , 1.0 mCi of Technetium-99m sulfur colloid was injected within the dermis surrounding the left breast biopsy site at four locations.  A 16-hour left anterior oblique imaging was performed with and without shielding of the original injection site.,FINDINGS:  ,There are two small foci of increased activity in the left axilla.  This is consistent with the sentinel lymph node.  No other areas of activity are visualized outside of the injection site and two axillary lymph nodes.,IMPRESSION:  ,Technically successful lymph node injection with two areas of increased activity in the left axilla consistent with sentinel lymph node.
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DESCRIPTION: Left breast cancer.  Nuclear medicine lymphatic scan.  A 16-hour left anterior oblique imaging was performed with and without shielding of the original injection site.

radiology, technetium-99m, mci, biopsy, breast cancer, nuclear medicine, lymphatic scan, lymph node, nuclear, breast,

The situation involves performing a nuclear medicine lymphatic scan for a patient with left breast cancer. This type of scan is crucial for identifying the sentinel lymph nodes, which are the first nodes to which cancer cells are likely to spread from the primary tumor. The accuracy of this scan is important for staging cancer and planning treatment, which directly impacts patient outcomes. Given the implications for a serious condition like breast cancer, the situation is indeed high-stakes for the patient's health.


Medical Specialty: Orthopedic
Sample Name: Rheumatology Progress Note

SUBJECTIVE:,  The patient is here for a follow-up.  The patient has a history of lupus, currently on Plaquenil 200-mg b.i.d.  Eye report was noted and appreciated.  The patient states that she is having some aches and pains of the hands and elbows that started recently a few weeks ago.  She denied having any trauma.  She states that the pain is bothering her.  She denies having any fevers, chills, or any joint effusion or swelling at this point.  She noted also that there is some increase in her hair loss in the recent times.,OBJECTIVE:,  The patient is alert and oriented.  General physical exam is unremarkable.  Musculoskeletal exam reveals positive tenderness in both lateral epicondyles of both elbows, no effusion.  Hand examination is unremarkable today.  The rest of the musculoskeletal exam is unremarkable.,ASSESSMENT:,  Epicondylitis, both elbows, possibly secondary to lupus flare-up.,PLAN:,  We will inject both elbows with 40-mg of Kenalog mixed with 1 cc of lidocaine.  The posterior approach was chosen under sterile conditions.  The patient tolerated both procedures well.  I will obtain CBC and urinalysis today.  If the patient's pain does not improve, I will consider adding methotrexate to her therapy.,Sample Doctor M.D.
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DESCRIPTION: Epicondylitis. history of lupus.  Injected with 40-mg of Kenalog mixed with 1 cc of lidocaine.

orthopedic, rheumatology, 1 cc of lidocaine, epicondylitis, kenalog, kenalog mixed with 1 cc of lidocaine, progress note, aches and pains, history of lupus, lidocaine, lupus, methotrexate, kenalog mixed, injected,

The situation involves a follow-up consultation for a patient with lupus, experiencing new musculoskeletal symptoms. While the condition itself may cause notable discomfort, the immediate actions to address this (such as injections and the consideration for additional medication) are part of standard management for such symptoms. The stakes are not life-threatening at this point but do require careful monitoring to manage lupus and prevent potential exacerbations effectively.


Medical Specialty: Neurology
Sample Name: Radiologic Exam - Spine

EXAM: , Cervical, lumbosacral, thoracic spine flexion and extension.,HISTORY: , Back and neck pain.,CERVICAL SPINE,FINDINGS:  ,AP, lateral with flexion and extension, and both oblique projections of the cervical spine demonstrate alignment and soft tissue structures to be unremarkable.
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DESCRIPTION: Cervical, lumbosacral, thoracic spine flexion and extension to evaluate back and neck pain.

neurology, radiologic exam, ap, back, cervical, oblique views, alignment, disc space, extension, fixation, flexion, foramina, intervertebral, lateral views, lumbosacral, neck, neck pain, oblique, odontoid view, pain, physiologic, projections, spine, subluxation, thoracic, flexion and extension, thoracic spine, vertebral

The situation involves an analysis of a radiologic exam focusing on the spine, addressing symptoms such as back and neck pain. While any medical examination has some importance, this specific case appears to report unremarkable findings in terms of alignment and soft tissue structures. This implies there are no immediate or apparent life-threatening issues present in the nasal structures of the cervical spine, based on the current information. Therefore, while monitoring and proper diagnosis are critical, the findings suggest a status that is not immediately critical or high-stakes. The stakes could increase if subsequent examinations revealed serious issues, but based on provided information, the stakes remain moderate.


Medical Specialty: Surgery
Sample Name: Colonoscopy - 15

PROCEDURE:,  Colonoscopy.,PREOPERATIVE DIAGNOSES: , Change in bowel habits and rectal prolapse.,POSTOPERATIVE DIAGNOSIS: , Normal colonoscopy.,PROCEDURE:  ,The Olympus pediatric variable colonoscope was introduced through the rectum and advanced carefully through the colon to the cecum identified by the ileocecal valve and the appendiceal orifice.  The preparation was poor, but mucosa was visible after lavage and suction.  Small lesions might have been missed in certain places, but no large lesions are likely to have been missed.  The mucosa was normal, was visualized.  In particular, there was no mucosal abnormality in the rectum and distal sigmoid, which is reported to be prolapsing.  Biopsies were taken from the rectal wall to look for microscopic changes.  The anal sphincter was considerably relaxed, with no tone and a gaping opening.  The patient tolerated the procedure well and was sent to recovery room.,FINAL DIAGNOSIS: , Normal colonic mucosa to the cecum.  No contraindications to consideration of a repair of the prolapse.
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DESCRIPTION: Colonoscopy.  Change in bowel habits and rectal prolapse.  Normal colonic mucosa to the cecum.

surgery, olympus, colonoscope, bowel habits, colonic mucosa, colonic, rectum, rectal, cecum, mucosa, colonoscopy,

The described situation involves a medical procedure, a colonoscopy, which is commonly performed to investigate issues like changes in bowel habits and rectal prolapse. The findings indicate a normal colonoscopy result, with no major issues detected, and biopsies were taken to further analyze potential microscopic changes. The procedure was tolerated well by the patient, and there are no contraindications for considering repair of the prolapse. Since this is a diagnostic procedure with a normal result and the situation appears stable, it indicates a moderate level of urgency rather than an extremely high-stakes scenario.