Medical Specialty: Gastroenterology
Sample Name: Blood In Toilet

CHIEF COMPLAINT:  ,Blood in toilet.,HISTORY: , Ms. ABC is a 77-year-old female who is brought down by way of ambulance from XYZ Nursing Home after nursing staff had noted there to be blood in the toilet after she had been sitting on the toilet.  They did not note any urine or stool in the toilet and the patient had no acute complaints.  The patient is unfortunately a poor historian in that she has dementia and does not recall any of the events.  The patient herself has absolutely no complaints, such as abdominal pain or back pain, urinary and GI complaints.  There is no other history provided by the nursing staff from XYZ.  There apparently were no clots noted within there.  She does not have a history of being on anticoagulants.,PAST MEDICAL HISTORY: , Actually quite limited, includes that of dementia, asthma, anemia which is chronic, hypothyroidism, schizophrenia, positive PPD in the past.,PAST SURGICAL HISTORY:  ,Unknown.,SOCIAL HISTORY: , No tobacco or alcohol.,MEDICATIONS: , Listed in the medical records.,ALLERGIES:,  No known drug allergies.,PHYSICAL EXAMINATION: , VITAL SIGNS:  Stable.,GENERAL:  This is a well-nourished, well-developed female who is alert, oriented in all spheres, pleasant, cooperative, resting comfortably, appearing otherwise healthy and well in no acute distress.,HEENT:  Visually normal.  Pupils are reactive.  TMs, canals, nasal mucosa, and oropharynx are intact.,NECK:  No lymphadenopathy or JVD.,HEART:  Regular rate and rhythm.  S1, S2.  No murmurs, gallops, or rubs.,LUNGS:  Clear to auscultation.  No wheeze, rales, or rhonchi.,ABDOMEN:  Benign, flat, soft, nontender, and nondistended.  Bowel sounds active.  No organomegaly or mass noted.,GU/RECTAL:  External rectum was normal.  No obvious blood internally.  There is no stool noted within the vault.  There is no gross amount of blood noted within the vault.  Guaiac was done and was trace positive.  Visual examination anteriorly during the rectal examination noted no blood within the vaginal region.,EXTREMITIES:  No significant abnormalities.,WORKUP: , CT abdomen and pelvis was negative.  CBC was entirely within normal limits without any signs of anemia with an H and H of 14 and 42%.  CMP also within normal limits.  PTT, PT, and INR were normal.  Attempts at getting the patient to give A urine were unsuccessful and the patient was very noncompliant, would not allow us to do any kind of Foley catheterization.,ER COURSE:,  Uneventful.  I have discussed the patient in full with Dr. X who agrees that she does not require any further workup or evaluation as an inpatient.  We have decided to send the patient back to XYZ with observation by the staff there.  She will have a CBC done daily for the next 3 days with results to Dr. X.  They are to call him if there is any recurrences of blood or worsening of symptoms and they are to do a urinalysis at XYZ for blood.,ASSESSMENT: , Questionable gastrointestinal bleeding at this time, stable without any obvious signs otherwise of significant bleed.
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DESCRIPTION: Blood in toilet.  Questionable gastrointestinal bleeding at this time, stable without any obvious signs otherwise of significant bleed.

The situation involves a 77-year-old patient experiencing an unexplained appearance of blood in the toilet, raising concerns about possible gastrointestinal bleeding. However, the patient remains stable, with no immediate distress or significant findings from examinations and tests. The decision to not hospitalize but instead observe at the nursing home with daily monitoring indicates that while it's a medical concern, it's not deemed an urgent life-threatening situation. The patient's age and medical conditions add complexity, but given the current stability and lack of acute symptoms, it's not extremely high-stakes.


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

Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Metastasectomy & Bronchoscopy

PREOPERATIVE DIAGNOSIS:  ,Metastatic renal cell carcinoma.,POSTOPERATIVE DIAGNOSIS:,  Metastatic renal cell carcinoma.,PROCEDURE PERFORMED:,  Left metastasectomy of metastatic renal cell carcinoma with additional mediastinal lymph node dissection and additional fiberoptic bronchoscopy used to confirm adequate placement of the double-lumen endotracheal tube with a tube thoracostomy, which was used to drain the left chest after the procedure.,ANESTHESIA:,  General endotracheal anesthesia with double-lumen endotracheal tube.,FINDINGS:,  Multiple pleural surface seeding, many sub-millimeter suspicious looking lesions.,DISPOSITION OF SPECIMENS:,To Pathology for permanent analysis as well as tissue banking.  The lesions sent for pathologic analysis were the following,,1.  Level 8 lymph node.,2.  Level 9 lymph node.,3.  Wedge, left upper lobe apex, which was also sent to the tissue bank and possible multiple lesions within this wedge.,4.  Wedge, left upper lobe posterior.,5.  Wedge, left upper lobe anterior.,6.  Wedge, left lower lobe superior segment.,7.  Wedge, left lower lobe diaphragmatic surface, anterolateral.,8.  Wedge, left lower lobe, anterolateral.,9.  Wedge, left lower lobe lateral adjacent to fissure.,10.  Wedge, left upper lobe, apex anterior.,11.  Lymph node package, additional level 8 lymph node.,ESTIMATED BLOOD LOSS:,  Less than 100 mL.,CONDITION OF THE PATIENT AFTER SURGERY: , Stable.,HISTORY OF PROCEDURE: , The patient was given preoperative informed consent for the procedure as well as for the clinical trial he was enrolled into.  The patient agreed based on the risks and the benefits of the procedure, which were presented to him and was taken to the operating room.  A correct time out procedure was performed.  The patient was placed into the supine position.  He was given general anesthesia, was endotracheally intubated without incident with a double-lumen endotracheal tube.  Fiberoptic bronchoscopy was used to perform confirmation of adequate placement of the double-lumen tube.  Following this, the decision was made to proceed with the surgery.  The patient was rolled into the right lateral decubitus position with the left side up.  All pressure points were padded.  The patient had a sterile DuraPrep preparation to the left chest.  A sterile drape around that was applied.  Also, the patient had Marcaine infused into the incision area.  Following this, the patient had a posterolateral thoracotomy incision, which was a muscle-sparing incision with a posterior approach just over the ausculatory triangle.  The incision was approximately 10 cm in size.  This was created with a 10-blade scalpel.  Bovie electrocautery was used to dissect the subcutaneous tissues.  The auscultatory triangle was opened.  The posterior aspect of the latissimus muscle was divided from the adjacent tissue and retracted anteriorly.  The muscle was not divided.  After the latissimus muscle was retracted anteriorly, the ribs were counted, and the sixth rib was identified.  The superior surface of the sixth rib was incised with Bovie electrocautery and the sixth rib was divided with rib shears.  Following this, the patient had the entire intercostal muscle separated from the superior aspect of the sixth rib on the left as far as the Bovie would reach.  The left lung was allowed to collapse and meticulous inspection of the left lung identified the lesions, which were taken out with stapled wedge resections via a TA30 green load stapler for all of the wedges.  The patient tolerated the procedure well without any complications.  The largest lesion was the left upper lobe apex lesion, which was possibly multiple lesions, which was taken in one large wedge segment, and this was also adjacent to another area of the wedges.  The patient had multiple pleural abnormalities, which were identified on the surface of the lung.  These were small white spotty looking lesions and were not confirmed to be tumor implants, but were suspicious to be multiple areas of tumor.  Based on this, the wedges of the tumors that were easily palpable were excised with complete excision of all palpable lesions.  Following this, the patient had a 32-French chest tube placed in the anteroapical position.  A 19-French Blake was placed in the posterior apical position.  The patient had the intercostal space reapproximated with #2-0 Vicryl suture, and the lung was allowed to be re-expanded under direct visualization.  Following this, the chest tubes were placed to Pleur-evac suction and the auscultatory triangle was closed with 2-0 Vicryl sutures.  The deeper tissue was closed with 3-0 Vicryl suture, and the skin was closed with running 4-0 Monocryl suture in a subcuticular fashion.  The patient tolerated the procedure well and had no complications.
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DESCRIPTION: Left metastasectomy of metastatic renal cell carcinoma with additional mediastinal lymph node dissection and additional fiberoptic bronchoscopy.

The documented procedure involves critical, invasive surgery related to metastatic cancer, specifically metastatic renal cell carcinoma in the lungs. Surgeries like metastasectomy and bronchoscopy to remove and confirm locations of cancerous tissues are high-stakes because they involve critical organs (lungs in this case) and are part of cancer treatment or management. Additionally, given that the patient was part of a clinical trial, outcomes could significantly affect not only the patient but also contribute to the broader medical understanding of the conditions involved. Serious complications or errors can lead to life-threatening consequences or impact future treatment plans. Thus, the stakes are high in both the immediate surgical context and the broader implications for cancer treatment.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Consult - History and Phy.
Sample Name: Exudative Tonsillitis

CHIEF COMPLAINT:  ,Severe tonsillitis, palatal cellulitis, and inability to swallow.,HISTORY OF PRESENT ILLNESS: , This patient started having sore throat approximately one week ago; however, yesterday it became much worse.  He was unable to swallow.  He complained to his parent.  He was taken to Med Care and did not get any better, and therefore presented this morning to ER, where seen and evaluated by Dr. X and concerned as whether he had an abscess either pharyngeal, palatal, or peritonsillar.  He was noted to have extreme tonsillitis with kissing tonsils, marked exudates especially right side and right palatal cellulitis.  A CT scan at ER did not show abscess.  He has not had airway compromise, but he has had difficulty swallowing.  He may have had a low-grade fever, but nothing marked at home.  His records from Hospital are reviewed as well as the pediatric notes by Dr. X. He did have some equivalent leukocytosis.  He had a negative monospot and negative strep screen.,PAST MEDICAL HISTORY:  ,The patient takes no medications, has had no illnesses or surgeries and he is generally in good health other than being significantly overweight.  He is a sophomore at High School.,FAMILY HISTORY:  ,Noncontributory to this illness.,SURGERIES: , None.,HABITS: , Nonsmoker, nondrinker.  Denies illicit drug use.,REVIEW OF SYSTEMS:,ENT:  The patient other than having dysphagia, the patient denies other associated ENT symptomatology.,GU:  Denies dysuria.,Orthopedic:  Denies joint pain, difficulty walking, etc.,Neuro:  Denies headache, blurry vision, etc.,Eyes:  Says vision is intact.,Lungs:  Denies shortness of breath, cough, etc.,Skin:  He states he has a rash, which occurred from penicillin that he was given IM yesterday at Covington Med Care.  Mildly itchy.  Mother has penicillin allergy.,Endocrine:  The patient denies any weight loss, weight gain, skin changes, fatigue, etc, essentially no symptoms of hyper or hypothyroidism.,Physical Exam:,General:  This is a morbidly obese white male adolescent, in no acute disease, alert and oriented x 4.  Voice is normal.  He is handling his secretions.  There is no stridor.,Vital Signs:  See vital signs in nurses notes.,Ears:  TM and EACs are normal.  External, normal.,Nose:  Opening clear.  External nose is normal.,Mouth:  Has bilateral marked exudates, tonsillitis, right greater than left.  Uvula is midline.  Tonsils are touching.  There is some redness of the right palatal area, but is not consistent with peritonsillar abscess.  Tongue is normal.  Dentition intact.  No mucosal lesions other than as noted.,Neck:  No thyromegaly, masses, or adenopathy except for some small minimally enlarged high jugular nodes.,Chest:  Clear to auscultation.,Heart:  No murmurs, rubs, or gallops.,Abdomen:  Obese.  Complete exam deferred.,Skin:  Visualized skin dry and intact, except for rash on his inner thighs and upper legs, which is red maculopapular and consistent with possible allergic reaction.,Neuro:  Cranial nerves II through XII are intact.  Eyes, pupils are equal, round, and reactive to light and accommodation, full range.,IMPRESSION: , Marked exudative tonsillitis, non-strep, non-mono, probably mixed anaerobic infection.  No significant prior history of tonsillitis.  Possible rash to PENICILLIN.,RECOMMENDATIONS: , I concur with IV clindamycin and IV Solu-Medrol as per Dr. X. I anticipate this patient may need several days of IV antibiotics and then be able to switch over to oral.  I do not insist that this patient will need surgical intervention since there is no evidence of abscess.  This one episode of severe tonsillitis does not mean the patient needs tonsillectomy, but if he continues to have significant tonsil problems after this he should be referred for ENT evaluation as an outpatient.  The patient's parents in the room had expressed good understanding, have a chance to ask questions.  At this time, I will see the patient back on an as needed basis.
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DESCRIPTION: Severe tonsillitis, palatal cellulitis, and inability to swallow.

The situation involves a severe case of exudative tonsillitis with complications such as palatal cellulitis and inability to swallow, requiring emergency care and IV medications. Although the patient does not currently have an abscess or airway compromise, the severity of symptoms and the need for IV treatment highlight the seriousness of the condition. However, it does not yet involve life-threatening complications, significant surgical interventions, or immediate risks to life, which would qualify it as higher stakes.


Medical Specialty: Surgery
Sample Name: Esophageal Foreign Body Removal

PREOPERATIVE DIAGNOSIS: , Esophageal foreign body.,POSTOPERATIVE DIAGNOSIS:,  Esophageal foreign body.,PROCEDURES PERFORMED:,1.  Direct laryngoscopy with intubation by surgeon.,2.  Rigid tracheoscopy.,3.  Rigid esophagoscopy with removal of foreign body.,INDICATIONS: , The patient is an 8-month-old Hispanic male, who presented to the Emergency Department with approximately 12-hour history of choking event and presumed for esophageal foreign body.  When seen in the Emergency Department, he was having no difficulty managing his secretions or any signs of any airway compromise.  Imaging in the Emergency Department did demonstrate an esophageal foreign body at or above the level of the cricopharyngeus.  Due to this, the patient was consented and taken urgently to the operating room for removal of this foreign body.,OPERATIVE DETAILS:,  The patient was correctly identified in the preop holding area and brought to operating room #37.  After informed consent was reviewed, general anesthesia was induced, initially with propofol, the existing IV.  Following this after protective eye tape was placed, #9 Parson's laryngoscope was introduced transorally and used to perform a direct laryngoscopy.  Normal anatomy was visualized.  Following this, a 4-mm, 20-rigid endoscope was introduced through the Parson's laryngoscope and used to perform a direct tracheoscopy.  The patient's supraglottis, glottis, and subglottis down to the level of the mid trachea were found to be benign with no abnormal-appearing anatomy.  Following this, the rigid endoscope was removed and the patient was intubated with a 4-0 endotracheal tube cuffed without difficulty.  After confirming bilateral breath sounds and positive end tidal CO2, this was secured to the patient by the anesthesia staff.  Following this, the Parson's laryngoscope was removed and a size 4 rigid esophagoscope was inserted transorally and passed down to the level of the patient's cricopharyngeus were the foreign body was visualized.  At this point, the coin grasper device was connected to the camera system and inserted through the existing esophagoscope.  This was used to grasp the coin and the coin was removed under direct visualization and handed off as a separate specimen.  Following this, the 34 mm 0-degree scope was inserted through the esophagoscope once the esophagoscope was passed down to the patient's GE junction.  The entire esophageal mucosa was examined as the esophagoscope was backed out and there was only a minimal amount of superficial ulceration in the posterior wall of the esophagus near the level of the cricopharyngeus muscle.  There were no other lesions or signs of further esophageal damage.  Following this, all instrumentation was removed, and care of the patient was turned back to the anesthesia staff for stable wakeup.,FINDINGS:,1.  Normal supraglottic, glottic, and subglottic anatomy.,2.  Esophageal foreign body at the level of the cricopharyngeus.,COMPLICATIONS:,  None.,ESTIMATED BLOOD LOSS:,  None.,DISPOSITION: , Stable to the PACU and then home.
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DESCRIPTION: Direct laryngoscopy and esophagoscopy with removal of foreign body

surgery, rigid tracheoscopy, rigid esophagoscopy, subglottic, supraglottic, glottic, removal of foreign body, level of the cricopharyngeus, esophageal foreign body, foreign body, rigid endoscope, direct laryngoscopy, emergency department, parson's laryngoscope, foreign, esophagoscopy, tracheoscopy, transorally, laryngoscopy, anesthesia, parson's, laryngoscope, endoscope, cricopharyngeus, esophagoscope, esophageal

The situation involves the removal of a foreign body (coin) from the esophagus of an 8-month-old infant. Although the procedure was successful and without complications, the initial risk of airway blockage or further complications due to the foreign body in such a young patient makes this a high-stakes situation. The urgent nature of the procedure and the need for general anesthesia in a very young child add to the stakes, even though the procedure concluded without incident.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Cervicalgia

FAMILY HISTORY: , Her father died at the age of 80 from prostate cancer.  Her mother died at the age of 67.  She did abuse alcohol.  She had a brother died at the age of 70 from bone and throat cancer.  She has two sons, ages 37 and 38 years old who are healthy.  She has two daughters, ages 60 and 58 years old, both with cancer.  She describes cancer hypertension, nervous condition, kidney disease, lung disease, and depression in her family.,SOCIAL HISTORY: , She is married and has support at home.  Denies tobacco, alcohol, and illicit drug use.,ALLERGIES: , Aspirin.,MEDICATIONS:  ,The patient does not list any current medications.,PAST MEDICAL HISTORY: , Hypertension, depression, and osteoporosis.,PAST SURGICAL HISTORY: , She has had over her over her lifetime four back surgeries and in 2005 she had anterior cervical discectomy and fusion of C3 through C7 by Dr. L.  She is G10, P7, no cesarean sections.,REVIEW OF SYSTEMS: , HEENT:  Headaches, vision changes, dizziness, and sore throat.  GI:  Difficulty swallowing.  Musculoskeletal:  She is right-handed with joint pain, stiffness, decreased range of motion, and arthritis.  Respiratory:  Shortness of breath and cough.  Cardiac:  Chest pain and swelling in her feet and ankle.  Psychiatric:  Anxiety and depression.  Urinary:  Negative and noncontributory.  Hem-Onc:  Negative and noncontributory.  Vascular:  Negative and noncontributory.  Genital:  Negative and noncontributory.,PHYSICAL EXAMINATION:,  On physical exam, she is 5 feet tall and currently weighs 110 pounds; weight one year ago was 145 pounds.  BP 138/78, pulse is 64.  General:  A well-developed, well-nourished female, in no acute distress.  HEENT exam, head is atraumatic and normocephalic.  Eyes, sclerae are anicteric.  Teeth, she does have some poor dentition.  She does say that she needs some of her teeth pulled on her lower mouth.  Cranial nerves II, III, IV, and VI, vision is intact and visual fields are full to confrontation.  EOMs are full bilaterally.  Pupils are equal, round, and reactive to light.  Cranial nerves V and VII, normal facial sensation and symmetrical facial movements.  Cranial nerve VIII, hearing is intact, although decreased bilaterally right worse than left.  Cranial nerves IX, X, and XII, tongue protrudes midline and palate elevates symmetrically.  Cranial nerve XI, strong and symmetrical shoulder shrugs against resistance.  Cardiac, regular rate and rhythm.  Chest and lungs are clear bilaterally.  Skin is warm and dry.  Normal turgor and texture.  No rashes or lesions are noted.  General musculoskeletal exam reveals no gross deformity, fasciculations, and atrophy.  Peripheral vascular, no cyanosis, clubbing, or edema.  She does have some tremoring of her bilateral upper arms as she said.  Strength testing reveals difficulty when testing due to the fact that the patient does have a lot of pain, but she seems to be pretty equal in the bilateral upper extremities with no obvious weakness noted.  She is about 4+/5 in the deltoids, biceps, triceps, wrist flexors, wrist extensors, dorsal interossei, and grip strength.,It is much more painful for her on the left.  Deep tendon reflexes are 2+ bilaterally only at biceps, triceps, and brachioradialis, knees, and ankles.  No ankle clonus is elicited.  Hoffmann's is negative bilaterally.  Sensation is intact.  She ambulates with slow short steps.  No spastic gait is noted.  She has appropriate station and gait with no assisted devices, although she states that she is supposed to be using a cane.  She does not bring one in with her today.,FINDINGS: , Patient brings in cervical spine x-rays and she has had an MRI taken but does not bring that in with her today.  She will obtain that and x rays, which showed at cervical plate C3, C4, C5, C6, and C7 anteriorly with some lifting with the most lifted area at the C3 level.  No fractures are noted.,ASSESSMENT: , Cervicalgia, cervical radiculopathy, and difficulty swallowing status post cervical fusion C3 through C7 with lifting of the plate.,PLAN:,  We went ahead and obtained an EKG in the office today, which demonstrated normal sinus rhythm.  She went ahead and obtained her x-rays and will pick her MRI and return to the office for surgical consultation with Dr. L first available.  She would like the plate removed, so that she can eat and drink better, so that she can proceed with her shoulder surgery.  All questions and concerns were addressed with her.  Warning signs and symptoms were gone over with her.  If she should have any further questions, concerns, or complications, she will contact our office immediately; otherwise, we will see her as scheduled.  I am quite worried about the pain that she is having in her arms, so I would like to see the MRI as well.  Case was reviewed and discussed with Dr. L.
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DESCRIPTION: Postoperative followup note - Cervicalgia, cervical radiculopathy, and difficulty swallowing status post cervical fusion C3 through C7 with lifting of the plate.

soap / chart / progress notes, c3 through c7, pain scale, mris, x-rays, cervical discectomy and fusion, cervical radiculopathy, cervical fusion, cervical discectomy, cervical plate, difficulty swallowing, cranial nerves, radiculopathy, discectomy, cervicalgia, postoperative, fusion, swallowing,

The situation involves a medical follow-up for a patient who is experiencing significant pain, has a history of multiple surgeries, and is currently facing complications following cervical fusion surgery. The presence of cervical radiculopathy and difficulty swallowing due to a potentially displaced plate are serious concerns. However, the patient is in no acute distress, and a plan for surgical consultation and further investigations (x-rays and MRI) is in place. Although the patient's condition requires attentive and efficient medical management, it does not indicate an immediate life-threatening emergency. Thus, the stakes are moderate as it concerns quality of life and potential surgical intervention.


Medical Specialty: Gastroenterology
Sample Name: Colonoscopy - 5

PROCEDURE: , Colonoscopy.,INDICATIONS: , Hematochezia, Personal history of colonic polyps.,MEDICATIONS:,  Midazolam 2 mg IV, Fentanyl 100 mcg IV,PROCEDURE:,  A History and Physical has been performed, and patient medication allergies have been reviewed.  The patient's tolerance of previous anesthesia has been reviewed.  The risks and benefits of the procedure and the sedation options and risks were discussed with the patient.  All questions were answered and informed consent was obtained.  Mental Status Examination:  alert and oriented.  Airway Examination:  normal oropharyngeal airway and neck mobility.  Respiratory Examination:  clear to auscultation.  CV Examination:  RRR, no murmurs, no S3 or S4.  ASA Grade Assessment:  P1 A normal healthy patient.  After reviewing the risks and benefits, the patient was deemed in satisfactory condition to undergo the procedure.  The anesthesia plan was to use conscious sedation.  Immediately prior to administration of medications, the patient was re-assessed for adequacy to receive sedatives.  The heart rate, respiratory rate, oxygen saturations, blood pressure, adequacy of pulmonary ventilation, and response to care were monitored throughout the procedure.  The physical status of the patient was re-assessed after the procedure.  After I obtained informed consent, the scope was passed under direct vision.  Throughout the procedure, the patient's blood pressure, pulse, and oxygen saturations were monitored continuously.  The colonoscope was introduced through the anus and advanced to the cecum, identified by appendiceal orifice & IC valve.  The quality of the prep was good.  The patient tolerated the procedure well.,FINDINGS:,1.  A sessile, non-bleeding polyp was found in the rectum.  The polyp was 5 mm in size.  Polypectomy was performed with a saline injection-lift technique using the snare.  Resection and retrieval were complete.  Estimated blood loss was minimal.,2.  One pedunculated, non-bleeding polyp was found in the sigmoid colon.  The polyp was 7 mm in size.  Polypectomy was performed with a hot forceps.  Resection and retrieval were complete.  Estimated blood loss was minimal.,3.  Multiple large-mouthed diverticula were found in the descending colon.,4.  Internal, non-bleeding, prolapsed with spontaneous reduction (grade II) hemorrhoids were found on retroflexion.,IMPRESSION:,1.  One 5 mm benign appearing polyp in the rectum.  Resected and retrieved.,2.  One 7 mm polyp in the sigmoid colon.  Resected and retrieved.,3.  Diverticulosis.,4.  Internal hemorrhoids were found.,RECOMMENDATION:,1.  High fiber diet.,2.  Await pathology results.,3.  Repeat colonoscopy for surveillance in 3 years.,4.  The findings and recommendations were discussed with the patient.,CPT CODE(S):,45385, Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by snare,technique.,45384, 59, Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by hot,biopsy forceps or bipolar cautery.,45381, 59, Colonoscopy, flexible, proximal to splenic flexure; with directed submucosal injection(s), any substance.,ICD9 CODE(S):,211.4, Benign neoplasm of rectum and anal canal.,211.3, Benign neoplasm of colon.,562.10, Diverticulosis of colon (without mention of hemorrhage).,455.2, Internal hemorrhoids with other complication,578.1, Blood in stool.,v12.72, Personal history of colonic polyps.
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DESCRIPTION: Colonoscopy due to hematochezia and personal history of colonic polyps.

The colonoscopy procedure described, while invasive, is considered routine and low-risk in the context of modern gastroenterological practice, particularly for a normal healthy patient (ASA Grade P1). The findings, including small polyps, diverticulosis, and hemorrhoids, are also common and largely benign conditions that are managed with standard care protocol such as polypectomy. The recommendations and follow-up procedures (e.g., high fiber diet, pathology, and repeat colonoscopy in 3 years) indicate standard post-procedural care. Given these factors, the situation does not involve significant immediate risk to the patient's health or involve critical decision-making at this time.


Medical Specialty: Gastroenterology
Sample Name: Laparoscopic Cholecystectomy - 9

PROCEDURE PERFORMED: , Laparoscopic cholecystectomy.,PROCEDURE:  ,After informed consent was obtained, the patient was brought to the operating room and placed supine on the operating room table.  General endotracheal anesthesia was induced without incident.  The patient was prepped and draped in the usual sterile manner.,A 2 cm infraumbilical midline incision was made.  The fascia was then cleared of subcutaneous tissue using a tonsil clamp.  A 1-2 cm incision was then made in the fascia, gaining entry into the abdominal cavity without incident.  Two sutures of 0 Vicryl were then placed superiorly and inferiorly in the fascia, and then tied to the special 12 mm Hasson trocar fitted with a funnel-shaped adapter in order to occlude the fascial opening.  Pneumoperitoneum was then established using carbon dioxide insufflation to a steady pressure of 16 mmHg.,The remaining trocars were then placed into the abdomen under direct vision of the 30 degree laparoscope taking care to make the incisions along Langer's lines, spreading the subcutaneous tissues with a tonsil clamp, and confirming the entry site by depressing the abdominal wall prior to insertion of the trocar.  A total of 3 other trocars were placed.  The first was a 10/11 mm trocar in the upper midline position.  The second was a 5 mm trocar placed in the anterior iliac spine.  The third was a 5 mm trocar placed to bisect the distance between the second and upper midline trocars.  All of the trocars were placed without difficulty.,The patient was then placed in reverse Trendelenburg position and was rotated slightly to the left.  The gallbladder was then grasped through the second and third trocars and retracted cephalad toward the right shoulder.  A laparoscopic dissector was then placed through the upper midline cannula, fitted with a reducer, and the structures within the triangle of Calot were meticulously dissected free.,A laparoscopic clip applier was introduced through the upper midline cannula and used to doubly ligate the cystic duct proximally and distally.  The duct was divided between the clips.  The clips were carefully placed to avoid occluding the juncture with the common bile duct.  The cystic artery was found medially and slightly posterior to the cystic duct.  It was carefully dissected free from its surrounding tissues.  A laparoscopic clip applier was introduced through the upper midline cannula and used to doubly ligate the cystic artery proximally and distally.  The artery was divided between the clips.  The 2 midline port sites were injected with 5% Marcaine.,After the complete detachment of the gallbladder from the liver, the video laparoscope was removed and placed through the upper 10/11 mm cannula.  The neck of the gallbladder was grasped with a large penetrating forceps placed through the umbilical 12 mm Hasson cannula.  As the gallbladder was pulled through the umbilical fascial defect, the entire sheath and forceps were removed from the abdomen.  The neck of the gallbladder was removed from the abdomen.  Following gallbladder removal, the remaining carbon dioxide was expelled from the abdomen.,Both midline fascial defects were then approximated using 0 Vicryl suture.  All skin incisions were approximated with 4-0 Vicryl in a subcuticular fashion.  The skin was prepped with benzoin, and Steri-Strips were applied.  Dressings were applied.  All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently extubated and taken to the recovery room in good and stable condition.
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DESCRIPTION: Laparoscopic cholecystectomy.  A 2 cm infraumbilical midline incision was made.  The fascia was then cleared of subcutaneous tissue using a tonsil clamp.

gastroenterology, langer's lines, laparoscope, cystic duct, cystic artery, laparoscopic cholecystectomy, midline cannula, infraumbilical, tonsil, cholecystectomy, fascia, abdomen, trocars, cannula, laparoscopic, gallbladder,

The situation is a detailed account of a laparoscopic cholecystectomy, which is a minimally invasive surgical procedure to remove the gallbladder. Although it is a common surgery, it involves general anesthesia and carries risks of complications such as injury to the bile ducts or bleeding. Therefore, the stakes involve maintaining patient safety and ensuring proper surgical technique to avoid complications. However, it is not considered a highly complex or rare procedure, suggesting moderate stakes in ensuring successful completion without complications.


Medical Specialty: Radiology
Sample Name: CT Neck - 2

FINDINGS:,There is a well demarcated mass lesion of the deep lobe of the left parotid gland measuring approximately 2.4 X 3.9 X 3.0cm (AP X transverse X craniocaudal) in size. The lesion is well demarcated. There is a solid peripheral rim with a mean attenuation coefficient of 56.3. There is a central cystic appearing area with a mean attenuation coefficient of 28.1 HU, suggesting an area of central necrosis. There is the suggestion of mild peripheral rim enhancement. This large lesion within the deep lobe of the parotid gland abuts and effaces the facial nerve. Primary consideration is of a benign mixed tumor (pleomorphic adenoma), however, other solid mass lesions cannot be excluded, for which histologic evaluation would be necessary for definitive diagnosis. The right parotid gland is normal.,There is mild enlargement of the left jugulodigastric node, measuring 1.1cm in size, with normal morphology (image #33/68). There is mild enlargement of the right jugulodigastric node, measuring 1.2cm in size, with normal morphology (image #38/68).,There are demonstrated bilateral deep lateral cervical nodes at the midlevel, measuring 0.6cm on the right side and 0.9cm on the left side (image #29/68). There is a second midlevel deep lateral cervical node demonstrated on the left side (image #20/68), measuring 0.7cm in size. There are small bilateral low level nodes involving the deep lateral cervical nodal chain (image #15/68) measuring 0.5cm in size.,There is no demonstrated nodal enlargement of the spinal accessory or pretracheal nodal chains.,The right parotid gland is normal and there is no right parotid gland mass lesion.,Normal bilateral submandibular glands.,Normal parapharyngeal, retropharyngeal and perivertebral spaces.,Normal carotid spaces.,IMPRESSION:,Large, well demarcated mass lesion of the deep lobe of the left parotid gland, with probable involvement of the left facial nerve. See above for size, morphology and pattern enhancement. Primary consideration is of a benign mixed tumor (pleomorphic adenoma), however, other solid mass lesions cannot be excluded, for which histologic evaluation is necessary for specificity.,Multiple visualized nodes of the bilateral deep lateral cervical nodal chain, within normal size and morphology, most compatible with mild hyperplasia.
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DESCRIPTION: CT REPORT - Soft Tissue Neck

CT REPORT - Soft Tissue Neck

radiology, cervical nodal, mass lesion, deep lobe, deep lateral, lateral cervical, parotid gland, cervical, lesion, gland, parotid, deep

The situation involves a CT scan of the neck revealing a mass in the left parotid gland, possibly a pleomorphic adenoma, which generally requires further evaluation and potential treatment. The mass abuts the facial nerve, raising considerations about potential nerve involvement, which could have significant implications for treatment and the patient's quality of life. Histologic evaluation is necessary to confirm the diagnosis and to rule out other solid mass lesions, which could be more serious. While the findings are concerning and warrant further investigation, they are not immediately life-threatening. However, the involvement of the facial nerve and potential for malignancy elevate the stakes to a moderate-to-high level.


Medical Specialty: Surgery
Sample Name: Tessio Catheter Insertion

OPERATIONS/PROCEDURES,1.  Insertion of right internal jugular Tessio catheter.,2.  Placement of left wrist primary submental arteriovenous fistula.,PROCEDURE IN DETAIL: , The patient was brought to the operating room and placed in the supine position.  Adequate general endotracheal anesthesia was induced.  Appropriate monitoring lines were placed.  The right neck, chest and left arm were prepped and draped in a sterile fashion.  A small incision was made at the top of the anterior jugular triangle in the right neck.  Through this small incision, the right internal jugular vein was punctured and a guidewire was placed.  It was punctured a 2nd time, and a 2nd guidewire was placed.  The Tessio catheters were assembled.  They were measured for length.  Counter-incisions were made on the right chest.  They were then tunneled through these lateral chest wall incisions to the neck incision, burying the Dacron cuffs.  They were flushed with saline.  A suture was placed through the guidewire, and the guidewire and dilator were removed.  The arterial catheter was then placed through this, and the tear-away introducer was removed.  The catheter aspirated and bled easily.  It was flushed with saline and capped.  This was repeated with the venous line.  It also aspirated easily and was flushed with saline and capped.  The neck incision was closed with a 4-0 Tycron, and the catheters were sutured at the exit sites with 4-0 nylon.  Dressings were applied.  An incision was then made at the left wrist.  The basilic vein was dissected free, as was the radial artery.  Heparin was given, 50 mg.  The radial artery was clamped proximally and distally with a bulldog.  It was opened with a #11 blade and Potts scissors, and stay sutures of 5-0 Prolene were placed.  The vein was clipped distally, divided and spatulated for anastomosis.  It was sutured to the radial artery with a running 7-0 Prolene suture.  The clamps were removed.  Good flow was noted through the artery.  Protamine was given, and the wound was closed with interrupted 3-0 Dexon subcutaneous and a running 4-0 Dexon subcuticular on the skin.  The patient tolerated the procedure well.
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DESCRIPTION: Insertion of right internal jugular Tessio catheter and placement of left wrist primary submental arteriovenous fistula.

surgery, internal jugular tessio catheter, arteriovenous, fistula, submental, tunneled, tessio catheter, internal jugular, radial artery, tessio, jugular, artery, catheterNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.

The situation described involves surgical insertion of a Tessio catheter and the creation of an arteriovenous fistula, which are significant medical procedures typically performed on patients requiring vascular access, such as for dialysis. These are high-stakes procedures due to the potential complications like infection, bleeding, or incorrect placement that can pose serious risks to the patient's health. The necessity for precise surgical technique and the use of general anesthesia further increase the stakes involved.


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

PREOPERATIVE DIAGNOSES,1.  Basal cell carcinoma, right cheek.,2.  Basal cell carcinoma, left cheek.,3.  Bilateral ruptured silicone gel implants.,4.  Bilateral Baker grade IV capsular contracture.,5.  Breast ptosis.,POSTOPERATIVE DIAGNOSES,1.  Basal cell carcinoma, right cheek.,2.  Basal cell carcinoma, left cheek.,3.  Bilateral ruptured silicone gel implants.,4.  Bilateral Baker grade IV capsular contracture.,5.  Breast ptosis.,PROCEDURE,1.  Excision of basal cell carcinoma, right cheek, 2.7 cm x 1.5 cm.,2.  Excision of basal cell carcinoma, left cheek, 2.3 x 1.5 cm.,3.  Closure complex, open wound utilizing local tissue advancement flap, right cheek.,4. Closure complex, open wound, left cheek utilizing local tissue advancement flap.,5.  Bilateral explantation and removal of ruptured silicone gel implants.,6.  Bilateral capsulectomies.,7.  Replacement with bilateral silicone gel implants, 325 cc.,INDICATIONS FOR PROCEDURES,The patient is a 61-year-old woman who presents with a history of biopsy-proven basal cell carcinoma, right and left cheek.  She had no prior history of skin cancer.  She is status post bilateral cosmetic breast augmentation many years ago and the records are not available for this procedure.  She has noted progressive hardening and distortion of the implant.  She desires to have the implants removed, capsulectomy and replacement of implants.  She would like to go slightly smaller than her current size as she has ptosis going with a smaller implant combined with capsulectomy will result in worsening of her ptosis.  She may require a lift.  She is not consenting to lift due to the surgical scars.,PAST MEDICAL HISTORY,Significant for deep venous thrombosis and acid reflux.,PAST SURGICAL HISTORY,Significant for appendectomy, colonoscopy and BAM.,MEDICATIONS,1.  Coumadin.  She stopped her Coumadin five days prior to the procedures.,2.  Lipitor,3.  Effexor.,4.  Klonopin.,ALLERGIES,None.,REVIEW OF SYSTEMS,Negative for dyspnea on exertion, palpitations, chest pain, and phlebitis.,PHYSICAL EXAMINATION,VITAL SIGNS:  Height 5'8", weight 155 pounds.,FACE:  Examination of the face demonstrates basal cell carcinoma, right and left cheek.  No lesions are noted in the regional lymph node base and no mass is appreciated.,BREAST:  Examination of the breast demonstrates bilateral grade IV capsular contracture.  She has asymmetry in distortion of the breast.  No masses are appreciated in the breast or the axilla.  The implants appear to be subglandular.,CHEST:  Clear to auscultation and percussion.,CARDIOVASCULAR:  Regular rate and rhythm.,EXTREMITIES:  Show full range of motion.  No clubbing, cyanosis or edema.,SKIN:  Significant environmental actinic skin damage.,I recommended excision of basal cell cancers with frozen section control of the margin, closure will require local tissue flaps.  I recommended exchange of the implants with reaugmentation.  No final size is guaranteed or implied.  We will decrease the size of the implants based on the intraoperative findings as the size is not known.  Several options are available.  Sizer implants will be placed to best estimate postoperative size.  Ptosis will be worse following capsulectomy and going with a smaller implant.  She may require a lift in the future.  We have obtained preoperative clearance from the patient's cardiologist, Dr. K.  The patient has been taken off Coumadin for five days and will be placed back on Coumadin the day after the surgery.  The risk of deep venous thrombosis is discussed.  Other risk including bleeding, infection, allergic reaction, pain, scarring, hypertrophic scarring and poor cosmetic resolve, worsening of ptosis, exposure, extrusion, the rupture of the implants, numbness of the nipple-areolar complex, hematoma, need for additional surgery, recurrent capsular contracture and recurrence of the skin cancer was all discussed, which she understands and informed consent is obtained.,PROCEDURE IN DETAIL,After appropriate informed consent was obtained, the patient was placed in the preoperative holding area with **** input.  She was then taken to the major operating room with ABCD Surgery Center, placed in a supine position.  Intravenous antibiotics were given.  TED hose and SCDs were placed.  After the induction of adequate general endotracheal anesthesia, she was prepped and draped in the usual sterile fashion.  Sites for excision and skin cancers were carefully marked with 5 mm margin.  These were injected with 1% lidocaine with epinephrine.,After allowing adequate time for basal constriction hemostasis, excision was performed, full thickness of the skin.  They were tagged at the 12 o'clock position and sent for frozen section.  Hemostasis was achieved using electrocautery.  Once margins were determined to be free of involvement, local tissue flaps were designed for advancement.  Undermining was performed.  Hemostasis was achieved using electrocautery.  Closure was performed under moderate tension with interrupted 5-0 Vicryl.  Skin was closed under loop magnification paying meticulous attention and cosmetic details with 6-0 Prolene.  Attention was then turned to the breast, clothes were changed, gloves were changed, incision was planned and the previous inframammary incision beginning on the right incision was made.  Dissection was carried down to the capsule.  It was extremely calcified.  Dissection of the anterior surface of the capsule was performed.  The implant was subglandular, the capsule was entered, implant was noted to be grossly intact; however, there was free silicone.  Implant was removed and noted to be ruptured.  No marking as to the size of the implant was found.,Capsulectomy was performed leaving a small portion in the axilla in the inframammary fold.  Pocket was modified to medialize the implant by placing 2-0 Prolene laterally in mattress sutures to restrict the pocket.  In identical fashion, capsulectomy was performed on the left.  Implant was noted to be grossly ruptured.  No marking was found for the size of the implant.  The entire content was weighed and found to be 350 grams.  Right side was weighed and noted to be 338 grams, although some silicone was lost in the transfer and most likely was identical 350 grams.  The implants appeared to be double lumen with the saline portion deflated.  Completion of the capsulectomy was performed on the left.
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DESCRIPTION: Excision of basal cell carcinoma.  Closure complex, open wound.  Bilateral capsulectomies.  Bilateral explantation and removal of ruptured silicone gel implants

The situation involves a complex medical procedure including the excision of basal cell carcinoma and breast implant surgeries. It is significant due to the multiple facets of the procedure and the patient's medical history, such as her past deep venous thrombosis and anticoagulant use, which present potential complications such as bleeding or thrombosis. Additionally, the patient's desire for cosmetic outcomes without further surgical scars adds complexity to the decision-making process. However, basal cell carcinoma typically has a low metastatic potential and the breast surgery is primarily reconstructive, making it less life-threatening, though still significant due to the intricacies involved and potential for complications.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Prostatitis - Recheck

SUBJECTIVE:,  The patient is a 65-year-old man with chronic prostatitis who returns for recheck.  He follow with Dr. XYZ about every three to four months.  His last appointment was in May 2004.  Has had decreased libido since he has been on Proscar.  He had tried Viagra with some improvement.  He has not had any urinary tract infection since he has been on Proscar.  Has nocturia x 3 to 4.,PAST MEDICAL HISTORY/SURGERIES/HOSPITALIZATIONS:  ,Soon after birth for treatment of an inperforated anus and curvature of the penis.  At the age of 70 had another penile operation.  At the age of 27 and 28 he had repeat operations to correct this.  He did have complications of deep vein thrombosis and pulmonary embolism with one of those operations.  He has had procedures in the past for hypospadias, underwent an operation in 1988 to remove some tissue block in the anus.  In January of 1991 underwent cystoscopy.  He was hospitalized in 1970 for treatment of urinary tract infection.  In 2001, left rotator cuff repair with acromioplasty and distal clavicle resection.  In 2001, colonoscopy that was normal.  In 2001, prostate biopsy that showed chronic prostatitis.  In 2003, left inguinal hernia repair with MESH.,MEDICATIONS:,  Bactrim DS one pill a day, Proscar 5 mg a day, Flomax 0.4 mg daily.  He also uses Metamucil four times daily and stool softeners for bedtime.,ALLERGIES:,  Cipro.,FAMILY HISTORY:,  Father died from CA at the age of 79.  Mother died from postoperative infection at the age of 81.  Brother died from pancreatitis at the age of 40 and had a prior history of mental illness.  Father also had a prior history of lung cancer.  Mother had a history of breast cancer.  Father also had glaucoma.  He does not have any living siblings.  Friend died a year and half ago.,PERSONAL HISTORY:,  Negative for use of alcohol or tobacco.  He is a professor at College and teaches history and bible.,REVIEW OF SYSTEMS:,Eyes, nose and throat:  Wears eye glasses.  Has had some gradual decreased hearing ability.,Pulmonary:  Denies difficulty with cough or sputum production or hemoptysis.,Cardiac:  Denies palpitations, chest pain, orthopnea, nocturnal dyspnea, or edema.,Gastrointestinal:  Has had difficulty with constipation.  He denies any positive stools.  Denies peptic ulcer disease.  Denies reflux or melena.,Genitourinary:  As mentioned previously.,Neurologic:  Without symptoms.,Bones and Joints:  He has had occasional back pain.,Hematologic:  Occasionally has had some soreness in the right axillary region, but has not had known lymphadenopathy.,Endocrine:  He has not had a history of hypercholesterolemia or diabetes.,Dermatologic:  Without symptoms.,Immunization:  He had pneumococcal vaccination about three years ago.  Had an adult DT immunization five years ago.,PHYSICAL EXAMINATION:,Vital Signs:  Weight:  202.8 pounds.  Blood pressure:  126/72.  Pulse:  60.  Temperature:  96.8 degrees.,General Appearance:  He is a middle-aged man who is not in any acute distress.,HEENT:  Eyes:  Pupils are equally regular, round and reactive to light.  Extraocular movements are intact without nystagmus.  Visual fields were full to direct confrontation.  Funduscopic exam reveals middle size disc with sharp margins.  Ears:  Tympanic membranes are clear.  Mouth:  No oral mucosal lesions are seen.,Neck:  Without adenopathy or thyromegaly.,Chest:  Lungs are resonant to percussion.  Auscultation reveals normal breath sounds.,Heart:  Normal S1 and S2 without gallops or rubs.,Abdomen:  Without tenderness or masses to palpation.,Genitorectal exam:  Not repeated since these have been performed recently by Dr. Tandoc.,Extremities:  Without edema.,Neurologic:  Reflexes are +2 and symmetric throughout.  Babinski is negative and sensation is intact.  Cranial nerves are intact without localizing signs.  Cerebellar tension is normal.,IMPRESSION/PLAN:,1.  Chronic prostatitis.  He has been stable in this regard.,2.  Constipation.  He is encouraged to continue with his present measures.  Additionally, a TSH level will be obtained.,3.  Erectile dysfunction.  Testosterone level and comprehensive metabolic profile will be obtained.,4.  Anemia.  CBC will be rechecked.  Additional stools for occult blood will be rechecked.
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DESCRIPTION: A 65-year-old man with chronic prostatitis returns for recheck.

This medical note outlines the follow-up appointment for a 65-year-old man with chronic prostatitis and several other health issues such as constipation, erectile dysfunction, and anemia. The patient's condition appears to be stable as mentioned under the Impression/Plan section, indicating that there are no urgent or life-threatening problems currently. However, there are health issues that need monitoring, such as chronic prostatitis and anemia, which could become more significant if not managed properly. The absence of urgent symptoms or conditions, such as severe pain, high fever, or severe acute distress, suggests this situation is not high-stakes. However, it remains an important routine check-up due to the patient's age and medical history.


Medical Specialty: Ophthalmology
Sample Name: Vitrectomy - Local Anesthesia

DESCRIPTION OF PROCEDURE:,  After appropriate operative consent was obtained the patient was brought supine to the operating room and placed on the operating room table.  After intravenous sedation was administered a retrobulbar block consisting of 2% Xylocaine with 0.75% Marcaine and Wydase was administered to the right eye without difficulty.  The patient's right eye was prepped and draped in sterile ophthalmic fashion and the procedure begun.  A wire lid speculum was inserted into the right eye and a limited conjunctival peritomy performed at the limbus temporally and superonasally.  Infusion line was set up in the inferotemporal quadrant and two additional sclerotomies were made in the superonasal and superotemporal quadrants.  A lens ring was secured to the eye using 7-0 Vicryl suture.
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DESCRIPTION: Vitrectomy under local anesthesia.

Vitrectomy under local anesthesia.

ophthalmology, lid speculum, conjunctival, peritomy, vitrectomy, operating, superonasally, anesthesiaNOTE,: 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.,

This scenario involves a surgical procedure on the eye, specifically a vitrectomy, which is a delicate and precise operation that entails removing some or all of the vitreous humor from the eye. However, it is being conducted under local anesthesia, suggesting the procedure is planned and controlled without immediate systemic health risks typically associated with general anesthesia or emergency surgeries. While it is a critical procedure, especially considering the potential impact on vision, it is routine in ophthalmology. The stakes are significant due to the potential risks associated with eye surgery (such as infection, bleeding, or vision loss), but they are not extremely high because it is a well-established procedure. Hence, it is crucial, but not life-threateningly urgent.


Medical Specialty: Dentistry
Sample Name: Dental Restoration

PREOPERATIVE DIAGNOSIS: , Dental caries.,POSTOPERATIVE DIAGNOSIS:,  Dental caries.,PROCEDURE: , Dental restoration.,CLINICAL HISTORY:  ,This 2-year, 10-month-old male has not had any prior dental treatment because of his unmanageable behavior in a routine dental office setting.  He was referred to me for that reason to be treated under general anesthesia for his dental work.  Cavities have been noted by his parents and pediatrician that have been noted to be pretty severe.  There are no contraindications to this procedure.  He is healthy.  His history and physical is in the chart.,PROCEDURE:  ,The patient was brought to the operating room at 10:15 and placed in the supine position.  Dr. X administered the general anesthetic after which 2 bite-wing and 2 periapical x-rays were exposed and developed and his teeth were examined.  A throat pack was then placed.  Tooth D had caries on the distal surface which was excavated and the tooth was restored with composite.  Teeth E and F had caries in the mesial and distal surfaces, these carious lesions were excavated and the teeth were restored with composite.  Tooth G had caries in the mesial surface which was excavated and the tooth was restored with composite.  Teeth I and L both had caries on the occlusal surfaces which were excavated and upon excavation of the caries in tooth I the pulp was perforated and a therapeutic pulpotomy was therefore necessary.  This was done using ferric sulfate and zinc oxide eugenol.  For final restorations, amalgam restorations were placed involving the occlusal surfaces both teeth I and L. A prophylaxis was done and topical fluoride applied and the excess was suctioned thoroughly.  The throat pack was removed and the patient was awakened and brought to the recovery room in good condition at 11:30.  There was no blood loss.
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DESCRIPTION: Dental restoration.    Dental caries.  Cavities have been noted by his parents and pediatrician that have been noted to be pretty severe.

dentistry, cavities, carious lesions, throat pack, composite teeth, occlusal surfaces, dental restoration, dental caries, dental, teeth, caries,

The situation involves a 2-year, 10-month-old child requiring dental restoration under general anesthesia due to severe dental caries. While the procedure is common in pediatric dentistry, the use of general anesthesia increases the complexity and potential risks associated with the procedure, particularly in young children. However, the procedure was completed without complications and the patient was reported to be in good condition post-operatively. Thus, the stakes are moderate because of the anesthesia requirement, but not extremely high as the procedure itself is standard and performed without issues.


Medical Specialty: Gastroenterology
Sample Name: Laparoscopy, Laparotomy, & Cholecystectomy

PREOPERATIVE DIAGNOSES: , Cholelithiasis, cholecystitis, and recurrent biliary colic.,POSTOPERATIVE DIAGNOSES: , Severe cholecystitis, cholelithiasis, choledocholithiasis, and morbid obesity.,PROCEDURES PERFORMED: , Laparoscopy, laparotomy, cholecystectomy with operative cholangiogram, choledocholithotomy with operative choledochoscopy and T-tube drainage of the common bile duct.,ANESTHESIA: , General.,INDICATIONS: , This is a 63-year-old white male patient with multiple medical problems including hypertension, diabetes, end-stage renal disease, coronary artery disease, and the patient is on hemodialysis, who has had recurrent episodes of epigastric right upper quadrant pain.  The patient was found to have cholelithiasis on last admission.  He was being worked up for this including cardiac clearance.  However, in the interim, he returned again with another episode of same pain.  The patient had a HIDA scan done yesterday, which shows nonvisualization of the gallbladder consistent with cystic duct obstruction.  Because of these, laparoscopic cholecystectomy was advised with cholangiogram.  Possibility of open laparotomy and open procedure was also explained to the patient.  The procedure, indications, risks, and alternatives were discussed with the patient in detail and informed consent was obtained.,DESCRIPTION OF PROCEDURE: , The patient was put in supine position on the operating table under satisfactory general anesthesia.  The entire abdomen was prepped and draped.  A small transverse incision was made about 2-1/2 inches above the umbilicus in the midline under local anesthesia.  The patient has a rather long torso.  Fascia was opened vertically and stay sutures were placed in the fascia.  Peritoneal cavity was carefully entered.  Hasson cannula was inserted into the peritoneal cavity and it was insufflated with CO2.  Laparoscopic camera was inserted and examination at this time showed difficult visualization with a part of omentum and hepatic flexure of the colon stuck in the subhepatic area.  The patient was placed in reverse Trendelenburg and rotated to the left.  An 11-mm trocar was placed in the subxiphoid space and two 5-mm in the right subcostal region.  Slowly, the dissection was carried out in the right subhepatic area.  Initially, I was able to dissect some of the omentum and hepatic flexure off the undersurface of the liver.  Then, some inflammatory changes were noted with some fatty necrosis type of changes and it was not quite clear whether this was part of the gallbladder or it was just pericholecystic infection/inflammation.  The visualization was extremely difficult because of the patient's obesity and a lot of fat intra-abdominally, although his abdominal wall is not that thick.  After evaluating this for a little while, we decided that there was no way that this could be done laparoscopically and proceeded with formal laparotomy.  The trocars were removed.,A right subcostal incision was made and peritoneal cavity was entered.  A Bookwalter retractor was put in place.  The dissection was then carried out on the undersurface of the liver.  Eventually, the gallbladder was identified, which was markedly scarred down and shrunk and appeared to have palpable stone in it.  Dissection was further carried down to what was felt to be the common bile duct, which appeared to be somewhat larger than normal about a centimeter in size.  The duodenum was kocherized.  The gallbladder was partly intrahepatic.  Because of this, I decided not to dig it out of the liver bed causing further bleeding and problem.  The inferior wall of the gallbladder was opened and two large stones, one was about 3 cm long and another one about 1.5 x 2 cm long, were taken out of the gallbladder.,It was difficult to tell where the cystic duct was.  Eventually after probing near the neck of the gallbladder, I did find the cystic duct, which was relatively very short.  Intraoperative cystic duct cholangiogram was done using C-arm fluoroscopy.  This showed a rounded density at the lower end of the bile duct consistent with the stone.  At this time, a decision was made to proceed with common duct exploration.  The common duct was opened between stay sutures of 4-0 Vicryl and immediately essentially clear bile came out.  After some pressing over the head of the pancreas through a kocherized maneuver, the stone did fall into the opening in the common bile duct.  So, it was about a 1-cm size stone, which was removed.  Following this, a 10-French red rubber catheter was passed into the common bile duct both proximally and distally and irrigated generously.  No further stones were obtained.  The catheter went easily into the duodenum through the ampulla of Vater.  At this point, a choledochoscope was inserted and proximally, I did not see any evidence of any common duct stones or proximally into the biliary tree.  However, a stone was found distally still floating around.  This was removed with stone forceps.  The bile ducts were irrigated again.  No further stones were removed.  A 16-French T-tube was then placed into the bile duct and the bile duct was repaired around the T-tube using 4-0 Vicryl interrupted sutures obtaining watertight closure.  A completion T-tube cholangiogram was done at this time, which showed slight narrowing and possibly a filling defect proximally below the confluence of the right and left hepatic duct, although externally, I was unable to see anything or palpate anything in this area.  Because of this, the T-tube was removed, and I passed the choledochoscope proximally again, and I was unable to see any evidence of any lesion or any stone in this area.  I felt at this time this was most likely an impression from the outside, which was still left over a gallbladder where the stone was stuck and it was impressing on the bile duct.  The bile duct lumen was widely open.  T-tube was again replaced into the bile duct and closed again and a completion T-tube cholangiogram appeared to be more satisfactory at this time.  The cystic duct opening through which I had done earlier a cystic duct cholangiogram, this was closed with a figure-of-eight suture of 2-0 Vicryl, and this was actually done earlier and completion cholangiogram did not show any leak from this area.,The remaining gallbladder bed, which was left in situ, was cauterized both for hemostasis and to burn off the mucosal lining.  Subhepatic and subdiaphragmatic spaces were irrigated with sterile saline solution.  Hemostasis was good.  A 10-mm Jackson-Pratt drain was left in the foramen of Winslow and brought out through the lateral 5-mm port site.  The T-tube was brought out through the middle 5-mm port site, which was just above the incision.  Abdominal incision was then closed in layers using 0 Vicryl running suture for the peritoneal layer and #1 Novafil running suture for the fascia.  Subcutaneous tissue was closed with 3-0 Vicryl running sutures in two layers.  Subfascial and subcutaneous tissues were injected with a total of 20 mL of 0.25% Marcaine with epinephrine for postoperative pain control.  The umbilical incision was closed with 0 Vicryl figure-of-eight sutures for the fascia, 2-0 Vicryl for the subcutaneous tissues, and staples for the skin.  Sterile dressing was applied, and the patient transferred to recovery room in stable condition.
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DESCRIPTION: Laparoscopy, laparotomy, cholecystectomy with operative cholangiogram, choledocholithotomy with operative choledochoscopy and T-tube drainage of the common bile duct.

gastroenterology, cholelithiasis, cholecystitis, biliary colic, choledocholithiasis, laparoscopy, laparotomy, cholecystectomy, cholangiogram, choledocholithotomy, choledochoscopy, t-tube drainage, cystic duct cholangiogram, common bile duct, peritoneal cavity, gallbladder

The scenario involves a complex surgical procedure on a 63-year-old male patient with significant comorbidities like hypertension, diabetes, end-stage renal disease, and coronary artery disease, who is on hemodialysis. The procedure had to be escalated from a laparoscopic approach to a more invasive open laparotomy due to complications encountered during the surgery. The presence of severe cholecystitis, cholelithiasis, choledocholithiasis, and morbid obesity further complicates the patient's situation. These factors contribute to a high-risk surgical procedure, with potential serious implications for the patient's health. Preoperative and postoperative care are crucial given the patient's other medical conditions, making this a high-stakes situation.


Medical Specialty: Orthopedic
Sample Name: CT C-Spine - 2

EXAM:,  CT cervical spine (C-spine) for trauma.,FINDINGS:,  CT examination of the cervical spine was performed without contrast.  Coronal and sagittal reformats were obtained for better anatomical localization.  Cervical vertebral body height, alignment and interspacing are maintained.  There is no evidence of fractures or destructive osseous lesions.  There are no significant degenerative endplate or facet changes.  No significant osseous central canal or foraminal narrowing is present.,IMPRESSION: , Negative cervical spine.
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DESCRIPTION: CT cervical spine for trauma.  CT examination of the cervical spine was performed without contrast.  Coronal and sagittal reformats were obtained for better anatomical localization.

orthopedic, c-spine, anatomical, degenerative endplate, ct examination, cervical spine, coronal, ct, spine, cervicalNOTE

The CT scan of the cervical spine for trauma has yielded negative results, meaning that there are no fractures, lesions, significant degenerative changes, or narrowing. This indicates that the patient's cervical spine is in good condition following the trauma event. While the initial situation of suspected trauma could be considered high-stakes, the findings show no immediate or long-term issues, which significantly reduce the stakes involved. However, the fact that this scan is for trauma suggests initial concern, slightly raising the stakes above routine procedures.


Medical Specialty: Orthopedic
Sample Name: Cemented Hemiarthroplasty & Biopsy

PREOPERATIVE DIAGNOSIS:,  Closed displaced probable pathological fracture, basicervical femoral neck, left hip.,POSTOPERATIVE DIAGNOSIS: , Closed displaced probable pathological fracture, basicervical femoral neck, left hip.,PROCEDURES PERFORMED:,1.  Left hip cemented hemiarthroplasty.,2.  Biopsy of the tissue from the fracture site and resected femoral head sent to the pathology for further assessment.,IMPLANTS USED:,1.  DePuy Ultima calcar stem, size 3 x 45.,2.  Bipolar head 28 x 43.,3.  Head with +0 neck length.,4.  Distal centralizer and cement restrictor.,5.  SmartSet antibiotic cement x2.,ANESTHESIA: , General.,NEEDLE AND SPONGE COUNT: , Correct.,COMPLICATIONS:  ,None.,ESTIMATED BLOOD LOSS: , 300 mL.,SPECIMEN: , Resected femoral head and tissue from the fracture site as well as the marrow from the canal.,FINDINGS:  ,On exposure, the fracture was noted to be basicervical pattern with no presence of calcar about the lesser trochanter.  The lesser trochanter was intact.  The fracture site was noted to show abnormal pathological tissue with grayish discoloration.  The quality of the bone was also pathologically abnormal with soft trabecular bone.  The abnormal pathological tissues were sent along with the femoral head to pathology for assessment.  Articular cartilage of the acetabulum was intact and well preserved.,INDICATION: , The patient is a 53-year-old female with a history of malignant melanoma, who apparently had severe pain in her left lower extremity and was noted to have a basicervical femoral neck fracture.  She denied any history of fall or trauma.  The presentation was consistent with pathological fracture pending tissue assessment.  Indication, risks, and benefits were discussed.  Treatment options were reviewed.  No guarantees have been made or implied.,PROCEDURE:  ,The patient was brought to the operating room and once an adequate general anesthesia was achieved, she was positioned on a pegboard with the left side up.  The left lower extremity was prepped and draped in a standard sterile fashion.  Time-out procedure was called.  Antibiotics were infused.,A standard posterolateral approach was made.  Subcutaneous dissection was performed and the dissection was carried down to expose the fascia of the gluteus maximus.  This was then incised along the line of the incision.  Hemostasis was achieved.  Charnley retractor was positioned.  The trochanter was intact.  The gluteus medius was well protected with retractor.  The piriformis and minimus junction was identified.  The minimus was also reflected along with the medius.  Using Bovie and knife, the piriformis and external rotators were detached from its trochanteric insertion.  Similarly, L-shaped capsulotomy was performed.  A #5 Ethibond was utilized to tag the piriformis and the capsule for late repair.  Fracture site was exposed.  The femoral neck fracture was noted to be very low-lying basicervical type.  Femoral head was retrieved without any difficulty with the help of a corkscrew.  The head size was measured to be 43 mm.  Bony fragments were removed.  The acetabular socket was thoroughly irrigated.  A 43-mm bipolar trial head was inserted and this was noted to give a satisfactory fit with good stability.  The specimens submitted to pathology included the resected femoral head and the tissue at the fracture site, which was abnormal with grayish discoloration.  This was sent to the pathology.  The fracture was noted to be basicervical and preoperatively, decision was made to consider cemented calcar stem.  An L-shaped osteotomy was performed in order to accept the calcar prosthesis.  The basicervical fracture was noted to be just at the level of superior border of the lesser trochanter.  There was no calcar superior to the lesser trochanter.  The L-shaped osteotomy was performed to refine the bony edges and accept the calcar prosthesis.  Hemostasis was achieved.  Now, the medullary canal was entered with a canal finder.  The fracture site was well exposed.  Satisfactory lateralization was performed.  Attention was for the reaming process.  Using a size 1 reamer, the medullary canal was entered and reamed up to size 3, which gave us a satisfactory fit into the canal.  At this point, a trial prosthesis size 3 with 45 mm calcar body was inserted.  Appropriate anteversion was positioned.  The anteversion was marked with a Bovie to identify subsequent anteversion during implantation.  The bony edges were trimmed.  The calcar implant with 45 mm neck length was fit in the host femur very well.  There was no evidence of any subsidence.  At this point, trial reduction was performed using a bipolar trial head with 0 neck length.  The relationship between the central femoral head and the greater trochanter was satisfactory.  The hip was well reduced without any difficulty.  The stability and range of motion in extension and external rotation as well as flexion-adduction, internal rotation was satisfactory.  The shuck was less than 1 mm.  Leg length was satisfactory in reference to the contralateral leg.  Stability was satisfactory at 90 degrees of flexion and hip at 75-80 degrees of internal rotation.  Similarly, keeping the leg completely adducted, I was able to internally rotate the hip to 45 degrees.  After verifying the stability and range of motion in all direction, trial components were removed.  The canal was thoroughly irrigated and dry sponge was inserted and canal was dried completely.  At this point, 2 batches of SmartSet cement with antibiotics were mixed.  The definitive Ultima calcar stem size 3 with 45 mm calcar body was selected.  Centralizer was positioned.  The cement restrictor was inserted.  Retrograde cementing technique was applied once the canal was dried.  Using cement gun, retrograde cementing was performed.  The stem was then inserted into cemented canal with appropriate anteversion, which was maintained until the cement was set hard and cured.  The excess cement was removed with the help of a curette and Freer elevator.  All the cement debris was removed.,Attention was now placed for the insertion of the trial femoral head.  Once again, 0 neck length trial bipolar head was inserted over the trunnion.  It was reduced and range of motion and stability was satisfactory.  I also attempted with a -3 trial head, but the 0 gave us a satisfactory stability, range of motion, as well as the length and the shuck was also minimal.  The hip was raised to 90 degrees of flexion and 95 degrees of internal rotation.  There was no evidence of any impingement on extension and external rotation as well as flexion-adduction, internal rotation.  I also tested the hip at 90 degrees of flexion with 10 degrees adduction and internal rotation and further progressive flexion of the hip beyond 90 degrees, which was noted to be very stable.  At this point, a definitive component using +0 neck length and bipolar 43 head were placed over the trunnion and the hip was reduced.  Range of motion and stability was as above.  Now, the attention was placed for the repair of the capsule and the external rotators and the piriformis.  This was repaired to the trochanteric insertion using #5 Ethibond and suture plaster.  Satisfactory reinforcement was achieved with the #5 Ethibond.  The wound was thoroughly irrigated.  Hemostasis was achieved.  The fascia was closed with #1 Vicryl followed by subcutaneous closure using 2-0 Vicryl.  The wound was thoroughly washed and a local injection with mixture of morphine and Toradol was infiltrated including the capsule and the pericapsular structures.  Skin was approximated with staples.  Sterile dressings were placed.  Abduction pillow was positioned and the patient was then extubated and transferred to the recovery room in a stable condition.  There were no intraoperative complications noted.
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DESCRIPTION: Left hip cemented hemiarthroplasty and biopsy of the tissue from the fracture site and resected femoral head sent to the pathology for further assessment.

The situation involves a surgical procedure for treating a patient with a probable pathological fracture in the hip. The stakes are higher than routine procedures due to the context: the patient's history of malignant melanoma raises the possibility of the fracture being pathological, possibly indicative of cancer-related complications. The procedure includes an orthopedic implant and a biopsy for pathological assessment, which are critical for the patient's immediate surgical outcome and potential long-term management of a serious underlying condition. Therefore, this situation has significant implications for the patient's health and future treatment plan.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Cardiac Catheterization - 3

INDICATIONS FOR PROCEDURE:, This is a 61-year-old, white male with onset of chest pain at 04: 30 this morning, with history of on and off chest discomfort over the past several days. CPK is already over 1000. There is ST elevation in leads II and aVF, as well as a Q wave. The chest pain is now gone, mild residual shortness of breath, no orthopnea. Cardiac monitor shows resolution of ST elevation lead III.,DESCRIPTION OF PROCEDURE:, Following sterile prep and drape of the right groin, installation of 1% Xylocaine anesthesia, the right common femoral artery was percutaneously entered and 6-French sheath inserted. ACT approximately 165 seconds on heparin. Borderline hypotension 250 mL fluid bolus given and nitroglycerin patch removed. Selective left and right coronary injections performed using Judkins coronary catheters with a 6-French pigtail catheter used to obtain left ventricular pressures and left ventriculography. Left pullback pressure. Sheath injection. Hemostasis obtained with a 6-French Angio-Seal device. He tolerated the procedure well and was transported to the Cardiac Step-Down Unit in stable condition.,HEMODYNAMIC DATA:, Left ventricular end diastolic pressure elevated post A-wave at 25 mm of Mercury with no aortic valve systolic gradient on pullback.,ANGIOGRAPHIC FINDINGS:,I. Left coronary artery: The left main coronary artery is unremarkable. The left anterior descending has 30 to 40% narrowing with tortuosity in its proximal portion, patent first septal perforator branch. The first diagonal branch is a 2 mm vessel with a 90% ostial stenosis. The second diagonal branch is unremarkable, as are the tiny distal diagonal branches. The intermediate branch is a small, normal vessel. The ostial non-dominant circumflex has some contrast thinning, but no stenosis, normal obtuse marginal branch, and small AV sulcus circumflex branch.,II. Right coronary artery: The right coronary artery is a large, dominant vessel which gives off large posterior descending and posterolateral left ventricular branches. There are luminal irregularities, less than 25%, within the proximal to mid vessel. Some contrast thinning is present in the distal RCA just before the bifurcation into posterior descending and posterolateral branches. A 25%, smooth narrowing at the origin of the posterior descending branch. Posterolateral branch is unremarkable and quite large, with secondary and tertiary branches.,III. Left ventriculogram: The left ventricle is normal in size. Ejection fraction estimated at 40 to 45%. No mitral regurgitation. Severe hypokinesis to akinesis is present in the posterobasal and posteromedial segments with normal anteroapical wall motion.,DISCUSSION:, Recent inferior myocardial infarction with only minor contrast thinning distal RCA remaining on coronary angiography with resolution of chest pain and ST segment elevation. Left coronary system has one hemodynamically significant stenosis (a 90% ostial stenosis at the first diagonal branch, which is a 2 mm vessel). Left ventricular function is reduced with ejection fraction 40 to 45% with inferior wall motion abnormality.,PLAN:, Medical treatment, including Plavix and nitrates, in addition to beta blocker, aspirin, and aggressive lipid reduction.
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DESCRIPTION: White male with onset of chest pain, with history of on and off chest discomfort over the past several days.

cardiovascular / pulmonary, cpk, q wave, st elevation, french angio-seal, pigtail catheter, st segment, ejection fraction, wall motion, diagonal branch, posterior descending, coronary artery, catheterization, circumflex, rca, cardiac, st, elevation, ventricular, stenosis, artery, coronary, branch,

The situation involves a 61-year-old male patient who has recently experienced a myocardial infarction (heart attack) with significant coronary artery blockage and reduced cardiac function. The procedure performed, cardiac catheterization, is crucial in diagnosing and managing coronary artery disease, a potentially life-threatening condition. Immediate and appropriate interventions are necessary to prevent further complications. The stakes involve potential risk to the patient's life and long-term health outcomes.


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

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

PREOPERATIVE DIAGNOSES,1.  Herniated disc, C5-C6.,2.  Cervical spondylosis, C5-C6.,POSTOPERATIVE DIAGNOSES,1.  Herniated disc, C5-C6.,2.  Cervical spondylosis, C5-C6.,PROCEDURES,1.  Anterior cervical discectomy with decompression, C5-C6.,2.  Anterior cervical fusion, C5-C6.,3.  Anterior cervical instrumentation, C5-C6.,4.  Allograft C5-C6.,ANESTHESIA:  ,General endotracheal.,COMPLICATIONS:,  None.,PATIENT STATUS: , Taken to recovery room in stable condition.,INDICATIONS: , The patient is a 36-year-old female who has had severe, recalcitrant right upper extremity pain, numbness, tingling, shoulder pain, axial neck pain, and headaches for many months.  Nonoperative measures failed to relieve her symptoms and surgical intervention was requested.  We discussed reasonable risks, benefits, and alternatives of various treatment options.  Continuation of nonoperative care versus the risks associated with surgery were discussed.  She understood the risks including bleeding, nerve vessel damage, infection, hoarseness, dysphagia, adjacent segment degeneration, continued worsening pain, failed fusion, and potential need for further surgery.  Despite these risks, she felt that current symptoms will be best managed operatively.,SUMMARY OF SURGERY IN DETAIL: , Following informed consent and preoperative administration of antibiotics, the patient was brought to the operating suite.  General anesthetic was administered.  The patient was placed in the supine position.  All prominences and neurovascular structures were well accommodated.  The patient was noted to have pulse in this position.  Preoperative x-rays revealed appropriate levels for skin incision.  Ten pound inline traction was placed via Gardner-Wells tongs and shoulder roll was placed.  The patient was then prepped and draped in sterile fashion.  Standard oblique incision was made over the C6 vertebral body in the proximal nuchal skin crease.  Subcutaneous tissue was dissected down to the level of the omohyoid which was transected.  Blunt dissection was carried out with the trachea and the esophagus in the midline and the carotid sheath in its vital structures laterally.  This was taken down to the prevertebral fascia which was bluntly split.  Intraoperative x-ray was taken to ensure proper levels.  Longus colli was identified and reflected proximally 3 to 4 mm off the midline bilaterally so that the anterior cervical Trimline retractor could be placed underneath the longus colli, thus placing no new traction on the surrounding vital structures.  Inferior spondylosis was removed with high-speed bur.  A scalpel and curette was used to remove the disc.  Decompression was carried posterior to the posterior longitudinal ligament down to the uncovertebral joints bilaterally.  Disc herniation was removed from the right posterolateral aspect of the interspace.  High-speed bur was used to prepare the endplate down to good bleeding bone and preparation for fusion.  Curette and ball tip dissector was then passed out the foramen and along the ventral aspect of the dura.  No further evidence of compression was identified.  Hemostasis was achieved with thrombin-soaked Gelfoam.  Interspace was then distracted with Caspar pin distractions set gently.  Interspace was then gently retracted with the Caspar pin distraction set.  An 8-mm allograft was deemed in appropriate fit.  This was press fit with demineralized bone matrix and tamped firmly into position achieving excellent interference fit.  The graft was stable to pull-out forces.  Distraction and traction was then removed and anterior cervical instrumentation was completed using a DePuy Trimline anterior cervical plate with 14-mm self-drilling screws.  Plate and screws were then locked to the plate.  Final x-rays revealed proper positioning of the plate, excellent distraction in the disc space, and apposition of the endplates and allograft.  Wounds were copiously irrigated with normal saline.  Omohyoid was approximated with 3-0 Vicryl.  Running 3-0 Vicryl was used to close the platysma.  Subcuticular Monocryl and Steri-Strips were used to close the skin.  A deep drain was placed prior to wound closure.  The patient was then allowed to awake from general anesthetic and was taken to the recovery room in stable condition.  There were no intraoperative complications.  All needle and sponge counts were correct.  Intraoperative neurologic monitoring was used throughout the entirety of the case and was normal.
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DESCRIPTION: Anterior cervical discectomy with decompression, anterior cervical fusion, anterior cervical instrumentation, and Allograft C5-C6.

surgery, cervical spondylosis, cervical fusion, decompression, instrumentation, anterior cervical discectomy, anterior cervical, herniated disc, cervical discectomy, anterior, cervical, fusion, allograft, discectomy

The situation involves a detailed surgical procedure, specifically an anterior cervical discectomy and decompression at the C5-C6 level. This type of surgery, while routine in some surgical practices, involves significant risks such as nerve damage, bleeding, and potential complications which were all acknowledged and communicated to the patient. The outcome of the surgery can have life-altering impacts on the patient's quality of life, potentially relieving severe symptoms or leading to further complications if anything goes wrong. These factors inherently make it a high-stakes situation. Given the successful completion and stable postoperative condition of the patient, the immediate stakes are mitigated, but the inherent risk and potential for serious complications justify a higher stakes level.


Medical Specialty: Discharge Summary
Sample Name: Kawasaki Disease - Discharge Summary

ADMITTING DIAGNOSIS: , Kawasaki disease.,DISCHARGE DIAGNOSIS:,  Kawasaki disease, resolving.,HOSPITAL COURSE:,  This is a 14-month-old baby boy Caucasian who came in with presumptive diagnosis of Kawasaki with fever for more than 5 days and conjunctivitis, mild arthritis with edema, rash, resolving and with elevated neutrophils and thrombocytosis, elevated CRP and ESR.  When he was sent to the hospital, he had a fever of 102.  Subsequently, the patient was evaluated and based on the criteria, he was started on high dose of aspirin and IVIG.  Echocardiogram was also done, which was negative.  IVIG was done x1, and between 12 hours of IVIG, he spiked fever again; it was repeated twice, and then after second IVIG, he did not spike any more fever.  Today, his fever and his rash have completely resolved.  He does not have any conjunctivitis and no redness of mucous membranes.  He is more calm and quite and taking good p.o.; so with a very close followup and a cardiac followup, he will be sent home.,DISCHARGE ACTIVITIES:,  Ad-lib.,DISCHARGE DIET: , PO ad-lib.,DISCHARGE MEDICATIONS: , Aspirin high dose 340 mg q.6h. for 1 day and then aspirin low dose 40 mg q.d. for 14 days and then Prevacid also to prevent his GI from aspirin 15 mg p.o. once a day.  He will be followed by his primary doctor in 2 to 3 days.  Cardiology for echo followup in 4 to 6 weeks and instructed not to give any vaccine in less than 11 months because of IVIG, all the live virus vaccine, and if he gets any rashes, any fevers, should go to primary care doctor as soon as possible.
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DESCRIPTION: This is a 14-month-old baby boy Caucasian who came in with presumptive diagnosis of Kawasaki with fever for more than 5 days and conjunctivitis, mild arthritis with edema, rash, resolving and with elevated neutrophils and thrombocytosis, elevated CRP and ESR.

discharge summary, mucous membranes, conjunctivitis, ad lib, kawasaki disease, vaccine, fever, aspirin

The situation involves the case of a 14-month-old baby diagnosed with Kawasaki Disease, which has critical health implications if not treated promptly. The child is being discharged with specific follow-up instructions and care, including a high dose of aspirin treatment and regular follow-ups with a cardiologist. Managing Kawasaki Disease properly is crucial to prevent long-term cardiovascular complications. The discharge summary includes important instructions, and adherence to these is vital for the child's health outcome. Therefore, the stakes are high due to the potential risks associated with improper follow-up care or ignoring symptoms.


Medical Specialty: Consult - History and Phy.
Sample Name: Murmur & Bacteremia.

REASON FOR CONSULTATION: , New murmur with bacteremia.,HISTORY OF PRESENT ILLNESS:,  The patient is an 84-year-old female admitted with jaundice and a pancreatic mass who was noted to have a new murmur, bacteremia, and fever.  The patient states that apart from the fever, she was having no other symptoms and denies any previous cardiac history.  She denies any orthopnea or paroxysmal nocturnal dyspnea.  Denies any edema, chest pain, palpitations, or syncope.  She has had TIAs in the past, but none recently.,PAST MEDICAL HISTORY:,  Significant for diabetes, hypertension, and TIA.,MEDICATIONS: , Include:,1.  Acidophilus supplement.,2.  Cholestyramine.,3.  Creon 20 three times daily.,4.  Diovan 160 mg twice daily.,6.  Lantus 10 daily.,7.  Norvasc 5 mg daily.,8.  NovoLog 70/30, 10 units at 12 noon daily.,9.  Pamelor 15 mL every evening.,10.  Vitamin D3 one tablet weekly.,ALLERGIES: , THE PATIENT IS ALLERGIC TO CODEINE, COREG, AND VANCOMYCIN.,FAMILY HISTORY:  ,The patient's daughter apparently has history of a murmur, but no diagnosis of congenital heart disease.  The patient's father died in his 80s of CHF.,SOCIAL HISTORY: , The patient denies ever having smoked, denies any significant alcohol use, and lives with her daughter in Pasadena.,REVIEW OF SYSTEMS: , The patient has had fever and chills.  She has also had some jaundice.  Denies any nausea or vomiting.  Denies any chest pain or abdominal pain.  Denies orthopnea, paroxysmal nocturnal dyspnea or edema.  She has had TIAs in the past, but denies any recent neurological symptoms such as motor weakness or focal sensory deficits.  Denies melena or hematochezia.  All other systems were reviewed and were found to be negative.,PHYSICAL EXAMINATION,GENERAL:  An elderly Caucasian female, awake and alert, and in no distress.,VITAL SIGNS:  Temperature is 98.8, heart rate 96, sinus, blood pressure 138/55, respiratory rate 20, and oxygen saturation 92%.,HEAD AND NECK:  Her head is atraumatic.  She is normocephalic.  Her neck is supple.  There is no JVD.  No palpable adenopathy or thyromegaly.  There is some icterus of the sclerae bilaterally.  Oral mucosa is moist.,CHEST:  Symmetrical expansion with normal percussion note.  There are no inspiratory crackles or expiratory wheeze.,CARDIAC:  Heart sounds S1 and S2 are regular.  There is a 2/6 systolic murmur heard through the precordium.  There is no gallop or rub.  There is no palpable thrill or retrosternal lift.,ABDOMEN:  Soft, nondistended, and nontender with normal bowel sounds.  No audible bruits.,EXTREMITIES:  No pitting edema, no clubbing, no cyanosis, and peripheral pulses are 2+.,NEUROLOGIC:  She exhibits no focal motor or sensory findings.,LABORATORY DATA: , The patient's sodium was 133, potassium 2.8, chloride 99, bicarbonate 31, glucose 75, BUN 12, creatinine 0.8, calcium 8.6, total bilirubin 3.2, AST 63, and ALT 43.  White count 5.4, hemoglobin 9.1, hematocrit 26.6, and platelet count 128,000.  Lipase less than 10.,DIAGNOSTIC IMAGING: , The patient had a CT scan of the abdomen that demonstrated a pancreatic mass with biliary obstruction.  Previous biliary stent was present.,EKG shows normal sinus rhythm.  There are no acute ST-T changes.,ASSESSMENT: , This is an 84-year-old female with newly found murmur.  No previous history of heart disease.  This murmur has occurred in the setting of fever and bacteremia.  The patient also has a pancreatic mass with jaundice, history of hypertension, and now has hyponatremia and hypokalemia.,PLAN:  ,The patient should undergo an echocardiogram to assess for the possibility of endocarditis, which may be contributing to her symptoms.  Blood pressure control should be maintained with Diovan and Norvasc.  Potassium should be replaced, and hyponatremia should be on proactive.
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DESCRIPTION: A female admitted with jaundice and a pancreatic mass who was noted to have a new murmur, bacteremia, and fever.

The patient is an elderly female with multiple serious conditions: a newly developed cardiac murmur, bacteremia, pancreatic mass, jaundice, and electrolyte imbalances. The potential for endocarditis adds significant risk, especially given her age and medical history. The presence of a pancreatic mass and jaundice may also indicate serious underlying malignancy or other critical illnesses that require urgent attention. These complex and interrelated health issues present a high-stakes situation.


Medical Specialty: Consult - History and Phy.
Sample Name: Cancer of the nasopharynx

DIAGNOSIS: , T1 N3 M0 cancer of the nasopharynx, status post radiation therapy with 2 cycles of high dose cisplatin with radiation, completed June, 2006; status post 2 cycles  carboplatin/5-FU given as adjuvant therapy, completed September, 2006; hearing loss related to chemotherapy and radiation; xerostomia; history of left upper extremity deep venous thrombosis.,PERFORMANCE STATUS:,  0.,INTERVAL HISTORY: , In the interim since his last visit he has done quite well.  He is working.  He did have an episode of upper respiratory infection and fever at the end of April which got better with antibiotics.  Overall when he compares his strength to six or eight months ago he notes that he feels much stronger.  He has no complaints other than mild xerostomia and treatment related hearing loss.,PHYSICAL EXAMINATION:,Vital Signs:  Height 65 inches, weight 150, pulse 76, blood pressure 112/74, temperature 95.4, respirations 18.,HEENT:  Extraocular muscles intact.  Sclerae not icteric.  Oral cavity free of exudate or ulceration.  Dry mouth noted.,Lymph:  No palpable adenopathy in cervical, supraclavicular or axillary areas.,Lungs:  Clear.,Cardiac:  Rhythm regular.,Abdomen:  Soft, nondistended.  Neither liver, spleen, nor other masses palpable.,Lower Extremities:  Without edema.,Neurologic:  Awake, alert, ambulatory, oriented, cognitively intact.,I reviewed the CT images and report of the study done on May 1.  This showed no evidence of metabolically active malignancy.,Most recent laboratory studies were performed last September and the TSH was normal.  I have asked him to repeat the TSH at the one year anniversary.,He is on no current medications.,In summary, this 57-year-old man presented with T1 N3 cancer of the nasopharynx and is now at 20 months post completion of all therapy.  He has made a good recovery.  We will continue to follow thyroid function and I have asked him to obtain a TSH at the one year anniversary in September and CBC in follow up.  We will see him in six months' time with a PET-CT.,He returns to the general care and direction of Dr. ABC.
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DESCRIPTION: T1 N3 M0 cancer of the nasopharynx, status post radiation therapy with 2 cycles of high dose cisplatin with radiation.

consult - history and phy., radiation therapy with cycles, cancer of the nasopharynx, status post radiation, cisplatin with radiation, radiation therapy, hearing loss, hearing, cisplatin, xerostomia, cancer, radiation, nasopharynx,

The patient's situation involves monitoring the recovery and potential recurrence of nasopharyngeal cancer, following significant treatment including radiation and chemotherapy. Given the nature of cancer as a potentially life-threatening condition, the stakes can be considered high due to the importance of ongoing monitoring to detect any recurrence or complications. However, the patient is currently reported to be doing well, with no active malignancy identified on recent imaging and a good recovery status noted, lessening immediate critical urgency. Further, there is a structured follow-up plan in place, enhancing the management of the situation.