Medical Specialty: Surgery
Sample Name: Bronchoscopy & Thoracotomy

PREOPERATIVE DIAGNOSES,1.  Bilateral bronchopneumonia.,2.  Empyema of the chest, left.,POSTOPERATIVE DIAGNOSES,1.  Bilateral bronchopneumonia.,2.  Empyema of the chest, left.,PROCEDURES,1.  Diagnostic bronchoscopy.,2.  Limited left thoracotomy with partial pulmonary decortication and insertion of chest tubes x2.,DESCRIPTION OF PROCEDURE:,  After obtaining an informed consent, the patient was taken to the operating room where a time-out process was followed.  Initially, the patient was intubated with a #6 French tube because of the presence of previous laryngectomy.  Because of this, I proceeded to use a pediatric bronchoscope, which provided limited visualization, but I was able to see the trachea and the carina and both left and right bronchial systems without significant pathology, although there was some mucus secretion that was aspirated.,Then, with the patient properly anesthetized and looking very stable, we decided to insert a larger endotracheal tube that allowed for the insertion of the regular adult bronchoscope.  Therefore, we were able to obtain a better visualization and see the trachea and the carina that were normal and also the left and right bronchial systems.  Some brownish secretions were obtained, particularly from the right side and were sent for culture and sensitivity, both aerobic and anaerobic fungi and acid fast.,Then, the patient was turned with left side up and prepped for a left thoracotomy.  He was properly draped.  I had recently re-inspected the CT of the chest and decided to make a limited thoracotomy of about 6 cm or so in the midaxillary line about the sixth intercostal space.  Immediately, it was evident that there was a large amount of pus in the left chest.  We proceeded to insert the suction catheters and we rapidly obtained about 1400 mL of frank pus.  Then, we proceeded to open the intercostal space a bit more with a Richardson retractor and it was immediately obvious that there was an abundant amount of solid exudate throughout the lung.  We spent several minutes trying to clean up this area.  Initially, I had planned only to drain the empyema because the patient was in a very poor condition, but at this particular moment, he was more stable and well oxygenated, and the situation was such that we were able to perform a partial pulmonary decortication where we broke up a number of loculations that were present and we were able to separate the lung from the diaphragm and also the pulmonary fissure.  On the upper part of the chest, we had limited access, but overall we obtained a large amount of solid exudate and we were able to break out loculations.  We followed by irrigation with 2000 cc of warm normal saline and then insertion of two #32 chest tubes, which are the largest one available in this institution; one we put over the diaphragm and the other one going up and down towards the apex.,The limited thoracotomy was closed with heavy intercostal sutures of Vicryl, then interrupted sutures of #0 Vicryl to the muscle layers, and I loosely approximately the skin with a few sutures of nylon because I am suspicious that the incision may become infected because he has been exposed to intrapleural pus.,The chest tubes were secured with sutures and then connected to Pleur-evac.  Then, the patient was transported.,Estimated blood loss was minimal and the patient tolerated the procedure well.  He was extubated in the operating room and he was transferred to the ICU to be admitted.  A chest x-ray was ordered stat.
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DESCRIPTION: Diagnostic bronchoscopy and limited left thoracotomy with partial pulmonary decortication and insertion of chest tubes x2.  Bilateral bronchopneumonia and empyema of the chest, left.

surgery, chest tubes, insertion, partial pulmonary decortication, thoracotomy, bronchoscopy, empyema, bronchopneumonia, diagnostic bronchoscopy, pulmonary decortication, bilateral bronchopneumonia, decortication, intercostal, pulmonary, tubes,

The situation involves a surgical procedure which consists of a diagnostic bronchoscopy and a thoracotomy for treating bilateral bronchopneumonia and left-sided empyema. These are serious medical conditions requiring complex interventions under anesthesia, highlighting the potential for significant complications if not managed properly. The involvement of bronchoscopy and thoracotomy suggests a need for precise surgical skills to diagnose and treat the infections effectively. Furthermore, the patient's history of prior laryngectomy and initial critical condition increase the stakes due to the elevated risk of complications. Additionally, the procedure addresses critical respiratory issues, which are potentially life-threatening if not handled adequately. Hence, the stakes of this scenario are high due to the critical nature of the surgery and potential risks involved.


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

Medical Specialty: Nephrology
Sample Name: Fogarty Thrombectomy

PREOPERATIVE DIAGNOSES:,1.  Chronic renal failure.,2.  Thrombosed left forearm arteriovenous Gore-Tex bridge fistula.,POSTOPERATIVE DIAGNOSIS:,1.  Chronic renal failure.,2.  Thrombosed left forearm arteriovenous Gore-Tex bridge fistula.,PROCEDURE PERFORMED:,1.  Fogarty thrombectomy, left forearm arteriovenous Gore-Tex bridge fistula.,2.  Revision of distal anastomosis with 7 mm interposition Gore-Tex graft.,ANESTHESIA:,  General with controlled ventillation.,GROSS FINDINGS: , The patient is a 58-year-old black male with chronic renal failure.  He undergoes dialysis through the left forearm bridge fistula and has small pseudoaneurysms at the needle puncture sites level.  There is narrowing at the distal anastomosis due to intimal hypoplasia and the vein beyond it was of good quality.,OPERATIVE PROCEDURE: , The patient was taken to the OR suite, placed in supine position.  General anesthetic was administered.  Left arm was prepped and draped in appropriate manner.  A Pfannenstiel skin incision was created just below the antecubital crease just deeper to the subcutaneous tissue.  Utilizing both blunt and sharp dissections segment of the fistula was isolated ________ vessel loop.  Transverse graftotomy was created.  A #4 Fogarty catheter passed proximally and distally restoring inflow and meager inflow.  A fistulogram was performed and the above findings were noted.  In a retrograde fashion, the proximal anastomosis was patent.  There was no narrowing within the forearm graft.  Both veins were flushed with heparinized saline and controlled with a vascular clamp.  A longitudinal incision was then created in the upper arm just deep into the subcutaneous tissue fascia.  Utilizing both blunt and sharp dissection, the brachial vein as well as distal anastomosis was isolated.  The distal anastomosis amputated off the fistula and oversewn with continuous running #6-0 Prolene suture tied upon itself.  The vein was controlled with vascular clamps.  Longitudinal venotomy created along the anteromedial wall.  A 7 mm graft was brought on to the field and this was cut to shape and size.  This was sewed to the graft in an end-to-side fashion with U-clips anchoring the graft at the heel and toe with interrupted #6-0 Prolene sutures.  Good backflow bleeding was confirmed.  The vein flushed with heparinized saline and graft was controlled with vascular clamp.  The end of the insertion graft was cut to shape in length and sutured to the graft in an end-to-end fashion with continuous running #6-0 Prolene suture.  Good backflow bleeding was confirmed.  The graftotomy was then closed with interrupted #6-0 Prolene suture.  Flow through the fistula was permitted, a good flow passed.  The wound was copiously irrigated with antibiotic solution.  Sponge, needles, instrument counts were correct.  All surgical sites were inspected.  Good hemostasis was noted.  The incision was closed in layers with absorbable sutures.  Sterile dressing was applied.  The patient tolerated the procedure well and returned to the recovery room in apparent stable condition.
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DESCRIPTION: Fogarty thrombectomy, left forearm arteriovenous Gore-Tex bridge fistula and revision of distal anastomosis with 7 mm interposition Gore-Tex graft.  Chronic renal failure and thrombosed left forearm arteriovenous Gore-Tex bridge fistula.

nephrology, chronic renal failure, thrombosed, gore-tex bridge fistula, arteriovenous, fogarty, thrombectomy, anastomosis, gore tex bridge, fogarty thrombectomy, prolene suture, renal failure, distal anastomosis, bridge fistula, interposition, renal, prolene

The situation involves a surgical procedure on a patient with chronic renal failure who is undergoing dialysis. The Fogarty thrombectomy and revision of the distal anastomosis are intended to restore proper function to the arteriovenous fistula used for dialysis. Such procedures are critical as they directly impact the patient's ability to receive dialysis, which is a life-sustaining treatment for patients with renal failure. Thus, successful outcomes are essential to maintaining the patient's quality of life and preventing severe complications. Hence, the stakes are high because the patient's ongoing treatment and health depend on the success of this procedure.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Surgery
Sample Name: Surgical Removal of Teeth

PREOPERATIVE DIAGNOSIS:,  Right buccal and canine's base infection from necrotic teeth.  ICD9 CODE:  528.3.,POSTOPERATIVE DIAGNOSIS: , Right buccal and canine's base infection from necrotic teeth.  ICD9 Code:  528.3.,PROCEDURE: , Incision and drainage of multiple facial spaces; CPT Code:  40801.  Surgical removal of the following teeth.  The teeth numbers 1, 2, 3, 4, and 5.  CPT code:  41899 and dental code 7210.,SPECIMENS: , Cultures and sensitivities were taken and sent for aerobic and anaerobic to the micro lab.,DRAINS:  ,A 1.5 inch Penrose drain placed in the right buccal and canine space.,ESTIMATED BLOOD LOSS:,  40 Ml.,FLUID:  ,700 mL of crystalloid.,COMPLICATIONS:  ,None.,CONDITION:  ,The patient was extubated breathing spontaneously to the PACU in good condition.,INDICATION FOR PROCEDURE:  ,The patient is a 41-year-old that has a recent history of toothache and tooth pain.  She saw her dentist in Sacaton before Thanksgiving who placed her on antibiotics and told her to return to the clinic for multiple teeth extractions.  The patient neglected to return to the dentist until this weekend for IV antibiotics and definitive treatment.  She noticed on Friday that her face was starting to swell up a little bit and it progressively got worse.  The patient was admitted to the hospital on Monday for IV antibiotics.  Oral surgery was consulted today to aid in the management of the increased facial swelling and tooth pain.  The patient was worked up preoperatively by anesthesia and Oromaxillary Facial Surgery.  It was determined that she would benefit from being having multiple teeth removed and drainage of the facial abscess under general anesthesia.  Risks, benefits, and alternatives of treatment were thoroughly discussed with the patient and consent was obtained.,DESCRIPTION OF PROCEDURE:,  The patient was taken to the operating room and laid on the operating room table on supine fashion.  ASA monitors were attached as stated.  General anesthesia was induced with IV anesthetic and maintained with a nasal endotracheal intubation and inhalation of anesthetics.  The patient was prepped and draped in usual oromaxillary facial surgery fashion.,An 18-gauze needle of 20 mL syringe was used to aspirate the pus out of the right buccal space.  This pus was then cultured and sent to micro lab for cultures and sensitivities.  Approximately 7 mL of 1% lidocaine with 1:1000 epinephrine was injected in the maxillary vestibule and palate.  After waiting appropriate time for local anesthesia to take affect a moist latex sponge was placed in the posterior oropharynx to throat pack throughout the case.  Mouth rinse was then poured into the oral cavity.  The mucosa was scrubbed with a tooth brush and peridex was evacuated with suction.  Using a #15 blade a clavicular incision from tooth #5 back to 1 with tuberosity release was performed.,A full thickness mucoperiosteal flap was developed and approximately 6 mL of pus was instantly drained from the buccal space.  It was noted on exam that the tooth #1 was fractured off to the gum line with gross decay.  Tooth #2, 3, 4, and 5 had pus leaking from the clavicular epithelium and had rampant decay on tooth #2 and 3 and some mobility on teeth #4 and 5.  It was decided that teeth #1 through 5 would be surgically removed to ensure that all potential teeth causing the abscess were removed.  Using a rongeur both buccal bone and the tooth 1, 2, 3, 4, and 5 were surgically removed.  The extraction sites were curetted with curettes and the bone was smoothed with the rongeur and the bone file.  Dissection was then carried further up in the canine space and the face was palpated extra orally from the temporalis muscle down to the infraorbital rim and more pus was expressed.  This site was then irrigated with copious amounts of sterile water.  There was still noted to be induration in the buccal mucosa so #15 blade was used anterior to Stensen duct.  A 2 cm incision was made and using a Hemostat blunt dissection in to the buccal mucosa was performed.  A little-to-no pus was received.  Using a half-inch Penrose the drain was placed up on the anterior border of the maxilla and zygoma and sutured in place with 2-0 Ethilon suture.  Remainder of the flap was left open to drain.  Further examination of the floor of mouth was soft.  The lateral pharynx was nonindurated or swollen.  At this point, the throat pack was removed and OG tube was placed and the stomach contents were evacuated.  The procedure was then determined to be over.  The patient was extubated, breathing spontaneously, and transferred to the PACU in excellent condition.
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DESCRIPTION: Right buccal and canine's base infection from necrotic teeth.  ICD9 CODE:  528.3.   Incision and drainage of multiple facial spaces; CPT Code:  40801.  Surgical removal of the following teeth.  The teeth numbers 1, 2, 3, 4, and 5.  CPT code:  41899 and dental code 7210.

surgery, cultures, buccal, teeth, canine, pacu, teeth extractions, oromaxillary facial, facial surgery, buccal space, throat pack, buccal mucosa, surgical removal, canine's base, necrotic teeth, cpt code, infection, oral, mucosa, anesthesia, facial, pus, toothache,

The situation involves a surgical procedure under general anesthesia to remove infected teeth and drain an abscess. While dental abscesses are common, they can become serious if not treated promptly, potentially leading to systemic infection or airway complications. The case has already escalated to requiring hospitalization and surgical intervention, indicating a moderate risk level. However, the procedure was performed successfully without complications, and the patient was in good condition postoperatively. Given these factors, the stakes are moderate due to the need for surgery and potential for serious complications if untreated.


Medical Specialty: Discharge Summary
Sample Name: Discharge Summary - 12

CURRENT HISTORY:,  A 94-year-old female from the nursing home with several days of lethargy and anorexia.  She was found to have evidence of UTI.  She also has renal insufficiency and digitalis toxicity.  She is admitted for further treatment.,Past medical history, social history, family history, physical examination can be seen on the admission H&P.,LABORATORIES ON ADMISSION: , White count 11,700, hemoglobin 12.8, hematocrit 37.2, BUN 91, creatinine 2.2, sodium 131, potassium 5.1.  Digoxin level of 4.1.,HOSPITAL COURSE: , The patient was admitted and intravenous fluids and antibiotics were administered.  Blood cultures were negative.  Urine cultures were nondiagnostic.  Renal function improved with creatinine down to 1 at the time of discharge.  Digoxin was restarted at a lower dose.  Her condition improved and she is stabilized and transferred back to assisted living in good condition.,PRIMARY DIAGNOSES:,1.  Urinary tract infection.,2.  Volume depletion.,3.  Renal insufficiency.,4.  Digitalis toxicity.,SECONDARY DIAGNOSES:,1.  Aortic valve stenosis.,2.  Congestive heart failure.,3.  Hypertension.,4.  Chronic anemia.,5.  Degenerative joint disease.,6.  Gastroesophageal reflux disease.,PROCEDURES:,  None.,COMPLICATIONS: , None.,DISCHARGE CONDITION: , Improved and stable.,DISCHARGE PLAN:  ,Physical activity:  With assistance.  ,Diet:  No restriction.  ,Medications:  Lasix 40 mg daily, lisinopril 5 mg daily, digoxin 0.125 mg daily, Augmentin 875 mg 1 tablet twice a day for 1 week, Nexium 40 mg daily, Elavil 10 mg at bedtime, Detrol 2 mg twice a day, potassium 10 mEq daily and diclofenac 50 mg twice a day.  ,Follow up:  She will see Dr. X in the office as scheduled.
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DESCRIPTION: A 94-year-old female from the nursing home with several days of lethargy and anorexia.  She was found to have evidence of UTI and also has renal insufficiency and digitalis toxicity.

The discharge summary describes the medical condition and treatment of a 94-year-old woman who displayed several serious health issues, such as a UTI, renal insufficiency, and digitalis toxicity, which required hospital admission. Her condition improved, and she is stable for transfer back to assisted living, suggesting successful treatment management. While her medical complexities make this situation important, the fact that she was stabilized and discharged indicates that the immediate distress is mitigated, classifying this as a moderate-stakes scenario rather than high-stakes. This is particularly within the context of chronic care management for a nursing home resident.


Medical Specialty: Neurosurgery
Sample Name: Craniotomy

TITLE OF OPERATION: , Right-sided craniotomy for evacuation of a right frontal intracranial hemorrhage.,INDICATION FOR SURGERY: , The patient is very well known to our service.  In brief, the patient is status post orbitozygomatic resection of a pituitary tumor with a very large intracranial component basically a very large skull-based brain tumor.  He was taken to the operating room for the orbitozygomatic approach.  Intraoperatively, everything went well without any complications.  The brain at the end of the procedure was absolutely intact, but the patient developed a seizure in the Intensive Care Unit and then was taken to the CT scan, developed a second seizure.  He was given Ativan for this, and then began to identify a large component measuring about 3 x 3 cm of the right frontal lobe, what appeared to be a hemorrhagic conversion of potential venous infarct.  I had a long discussion immediately with Dr. X and Dr. Y.  We decided to take the patient immediately as a level 1 for evacuation of this hematoma with a small amount of a midline shift with an intraventricular component.  It worried me and I think that we needed to go ahead and take him to the operating room immediately.  The patient was taken as a level 1 immediately and emergently and into the operating room for this procedure.  The original plan was to do first a right-sided orbitozygomatic procedure and then stage it a few weeks later with an endonasal endoscopic procedure for resection of this pituitary tumor component.  He was taken to the operating room for evacuation of a right frontal intraparenchymal hematoma.,PREOP DIAGNOSIS:,  Pituitary tumor with a large intracranial component, status post resection and now development of an intracranial hemorrhage.,POSTOP DIAGNOSIS:,  Intracranial hemorrhage in the right frontal lobe with extension into the intraventricular space after resection of a pituitary tumor via orbitozygomatic approach.,ANESTHESIA: , General.,PROCEDURE IN DETAIL: , The patient was taken to the operating room.  In the supine position, his head was put in a horseshoe without any complications.  The patient tolerated this very well, and the prior incision was immediately opened.  The surgery had taken place a few hours prior to this, the original orbitozygomatic approach.  At this point, this was a life-saving procedure.  We went ahead, opened the old incision after everything was sterilely prepped, and all the surgical instrumentation was brought into place.  We went ahead and opened the incision and took out the pterional bone flap without any complications.  We immediately opened the dura expeditiously, and the brain was moderately under some pressure, but not really bulging out.  So I went ahead and identified an area over the right frontal lobe that was a little bit consistent with a hemorrhagic infarct and nonviable tissue.  So we went ahead and did a corticectomy right there and identified the actual clot immediately and went ahead, and over the next few hours, very meticulously began to evacuate these clots without any complication whatsoever.  We went all the way down to the ventricle and identified this clot in the ventricle and went ahead and removed this clot without any complications, and we had a very nice resection.  The brain was very relaxed.  We had a very good resection of the actual blood clot, and the brain was very relaxed.  We irrigated thoroughly.  We identified the ventricles.  We went ahead and did a very careful hemostasis with Avitene with thrombin and Gelfoam with thrombin over the next times in doing the procedure.  All this was done very well, and then we lined the cavity with Surgicel, and the Surgicel was only put at the edge and draping down as to not to leave any fragments potentially to communicate with the actual ventricle, and then after this, everything was good.  We went ahead and closed back the actual dura back.  We had done a pericranial flap.  This was also put back in place and the dura was closed with 4-0 Surgilons.  We reconstructed everything.  The frontal sinus was reconstructed thoroughly without any complications.  We went ahead and put once again a watertight closure and went ahead and put another piece of DuraGen with Hemaseel in place, and went ahead and put the bone flap back and reconstructed very nicely once again with self-tapping, self-drilling screws, low-profile plates.  Once everything was confirmed to be in place, we went ahead and closed the muscle flap and also the actual fat pad was put back into place and closed together with 0 pop-offs, and the skin with staples without any complications.  In summary, the procedure was going back to the operating room for evacuation of a right-sided intracranial hemorrhage, most likely a conversion of an intraparenchymal hematoma with extension into the ventricle without any complications.  So everything was stable.  Estimated blood loss was about 100 cubic centimeters.  The sponges and needle counts were correct.  No specimens were sent to pathology.,DISPOSITION: , The patient after this procedure was brought to the Neuro Intensive Care Unit for close observation.
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DESCRIPTION: Right-sided craniotomy for evacuation of a right frontal intracranial hemorrhage.  Status post orbitozygomatic resection of a pituitary tumor with a very large intracranial component basically a very large skull-based brain tumor.

neurosurgery, orbitozygomatic, intracranial, brain tumor, intraparenchymal hematoma, orbitozygomatic approach, frontal lobe, intracranial hemorrhage, pituitary tumor, craniotomy, hemorrhage,

This situation involves performing neurosurgery on a patient who developed a serious complication (intracranial hemorrhage) after an initial surgical procedure to resect a large pituitary tumor. Intracranial hemorrhage, especially when accompanied by seizures and brain pressure changes, necessitates urgent surgical intervention. In this case, a craniotomy was performed as an emergency, life-saving measure. Any neurosurgical procedure carries significant risks, but the emergency nature of this operation and its potential impact on the patient's survival make it a high-stakes scenario.


Medical Specialty: Radiology
Sample Name: Carotid Doppler Report

Grade II:  Atherosclerotic plaques are seen which appear to be causing 40-60% obstruction.,Grade III:  Atherosclerotic plaques are seen which appear to be causing greater than 60% obstruction.,Grade IV:  The vessel is not pulsating and the artery appears to be totally obstructed with no blood flow in it.,RIGHT CAROTID SYSTEM: , The common carotid artery and bulb area shows mild intimal thickening with no increase in velocity and no evidence for any obstructive disease.  The internal carotid artery shows intimal thickening with some mixed plaques, but no increase in velocity and no evidence for any significant obstructive disease.  The external carotid artery shows no disease.  The vertebral was present and was antegrade.,LEFT CAROTID SYSTEM: , The common carotid artery and bulb area shows mild intimal thickening, but no increase in velocity and no evidence for any significant obstructive disease. the internal carotid artery shows some intimal thickening with mixed plaques, but no increase in velocity and no evidence for any significant obstructive disease.  The external carotid artery shows no disease.  The vertebral was present and was antegrade.,IMPRESSION:,  Bilateral atherosclerotic changes with no evidence for any significant obstructive disease.
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DESCRIPTION: Carotid Ultrasonic & Color Flow Imaging

Carotid Ultrasonic & Color Flow Imaging

radiology, atherosclerotic, atherosclerotic plaques, obstructive disease, carotid artery, carotid artery and bulb, common carotid artery, mild intimal thickening, external carotid artery, common carotid, internal carotid, external carotid, intimal thickening, carotid, intimal, plaques, artery,

The report describes a carotid Doppler scan with findings of mild atherosclerotic changes that do not result in significant obstruction of the carotid arteries. The impression indicates there is no significant obstructive disease, which suggests that the patient is not at immediate risk of a severe event like a stroke as a result of this scan. However, it is still important information for long-term cardiovascular risk management and monitoring by healthcare providers. The stakes are mainly related to ongoing monitoring and potential lifestyle or medical management changes rather than immediate high-risk intervention.


Medical Specialty: Surgery
Sample Name: BICAP Cautery

PREOPERATIVE DIAGNOSIS: ,  Hematemesis in a patient with longstanding diabetes. ,POSTOPERATIVE DIAGNOSIS:  ,Mallory-Weiss tear, submucosal hemorrhage consistent with trauma from vomiting and grade 2 esophagitis.,PROCEDURE:  , The procedure, indications explained and he understood and agreed.  He was sedated with Versed 3, Demerol 25 and topical Hurricane spray to the oropharynx.  A bite block was placed.  The Pentax video gastroscope was advanced through the oropharynx into the esophagus under direct vision.  Esophagus revealed distal ulcerations.  Additionally, the patient had a Mallory-Weiss tear.  This was subjected to bicap cautery with good ablation.  The stomach was entered, which revealed areas of submucosal hemorrhage consistent with trauma from vomiting.  There were no ulcerations or erosions in the stomach.  The duodenum was entered, which was unremarkable.  The instrument was then removed.  The patient tolerated the procedure well with no complications.,IMPRESSION: , Mallory-Weiss tear, successful BICAP cautery. ,We will keep the patient on proton pump inhibitors.  The patient will remain on antiemetics and be started on a clear liquid diet.
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DESCRIPTION: Hematemesis in a patient with longstanding diabetes.   Submucosal hemorrhage consistent with trauma from vomiting and grade 2 esophagitis.  Mallory-Weiss tear, successful BICAP cautery.

surgery, mallory-weiss tear, submucosal hemorrhage, esophagitis, vomiting, bicap cautery, mallory weiss, diabetes, esophagus, submucosal, hemorrhage, trauma, hematemesis,

The described situation involves a surgical procedure for addressing a Mallory-Weiss tear in a patient experiencing hematemesis. Although the procedure was conducted successfully and the patient tolerated it well, the context includes serious concerns such as hematemesis and the risk of further complications, particularly given the patient's longstanding diabetes. These factors make it a moderate to high-stakes situation due to the potential for severe outcomes if not properly managed and monitored. However, the immediate state post-procedure appears stable, lowering the immediate risk slightly.


Medical Specialty: Lab Medicine - Pathology
Sample Name: BNP v/s BMP

BNP, (brain natriuretic peptide or B-type natriuretic peptide) is a substance produced in the  heart ventricles when there is excessive strain to the heart muscles.  A blood test for this can be used as an effective parameter for detecting an acute event of congestive heart failure, where the heart is unable to pump sufficient amount of blood required by the body's needs.  When a person has a heart failure (such as MI), BNP is secreted so immensely that it sits well above the measurable range.  Values above 100 signal a problematic situation and those above 500 a highly demanding state.  Note that a person with a remote history of heart problems may not have BNP levels elevated, but it is used as a measure of acute events.,On the other hand, ,BMP, or basic metabolic panel is not a single test but a group of 8 tests (glucose, calcium, sodium, potassium, bicarbonate, chloride, BUN, creatinine).  Any test that has the word panel in it is not a single test, so cannot have a single value.,With this logic in mind, if a doctor uses phrases like "BNP/BMP is elevated/negative/positive/is greater than/less than etc." and then a single value, it may not be BMP.  You can also take the hint from the file whether the patient presented to the hospital with an acute coronary event.  Likewise, if he says multiple values for this test, this must be BMP.,
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DESCRIPTION: Is it BNP or BMP?

Is it BNP or BMP?

lab medicine - pathology, brain natriuretic peptide, b-type natriuretic peptide, basic metabolic panel, glucose, calcium, sodium, potassium, bicarbonate, chloride, bun, creatinine, natriuretic peptide, bmp, bnp,

The situation involves distinguishing between two types of medical tests, BNP and BMP, in the context of a healthcare setting. BNP is specifically related to heart strain and heart failure, providing crucial information for acute medical situations, while BMP involves multiple blood tests offering a broad picture of a patient's metabolic state. While accurate interpretation of these tests is important for patient treatment, this query involves standard laboratory test deciphering and not an immediate life-or-death decision. An incorrect interpretation could delay the right diagnosis but it doesn't directly result in immediate harm compared to a surgical decision or emergency intervention. Therefore, the stakes are relatively moderate.


Medical Specialty: Surgery
Sample Name: Heart Catheterization - 2

PROCEDURE PERFORMED:,  Right heart catheterization.,INDICATION: , Refractory CHF to maximum medical therapy.,PROCEDURE: , After risks, benefits, and alternatives of the above-mentioned procedure were explained to the patient and the patient's family in detail, informed consent was obtained both verbally and in writing.  The patient was taken to Cardiac Catheterization Suite where the right internal jugular region was prepped and draped in the usual sterile fashion.  1% lidocaine solution was used to infiltrate the skin overlying the right internal jugular vein.  Once adequate anesthesia has been obtained, a thin-walled #18 gauge Argon needle was used to cannulate the right internal jugular vein.  A steel guidewire was then inserted through the needle into the vessel without resistance.  Small nick was then made in the skin and the needle was removed.  An #8.5 French venous sheath was then advanced over the guidewire into the vascular lumen without resistance.  The guidewire and dilator were then removed.  The sheath was then flushed.  A Swan-Ganz catheter was inserted to 20 cm and the balloon was inflated.  Under fluoroscopic guidance, the catheter was advanced into the right atrium through the right ventricle and into the pulmonary artery wedge position.  Hemodynamics were measured along the way.  Pulmonary artery saturation was obtained.  The Swan was then kept in place for the patient to be transferred to the ICU for further medical titration.  The patient tolerated the procedure well.  The patient returned to the cardiac catheterization holding area in stable and satisfactory condition.,FINDINGS:,  Body surface area equals 2.04, hemoglobin equals 9.3, O2 is at 2 liters nasal cannula.  Pulmonary artery saturation equals 37.8.  Pulse oximetry on 2 liters nasal cannula equals 93%.  Right atrial pressure is 8, right ventricular pressure equals 59/9, pulmonary artery pressure equals 61/31 with mean of 43, pulmonary artery wedge pressure equals 21, cardiac output equals 3.3 by the Fick method, cardiac index is 1.6 by the Fick method, systemic vascular resistance equals 1821, and transpulmonic gradient equals 22.,IMPRESSION:  ,Exam and Swan findings consistent with low perfusion given that the mixed venous O2 is only 38% on current medical therapy as well as elevated right-sided filling pressures and a high systemic vascular resistance.,PLAN: , Given that the patient is unable to tolerate vasodilator therapy secondary to significant orthostasis and the fact that the patient will not respond to oral titration at this point due to lack of cardiac reserve, the patient will need to be discharged home on Primacor.  The patient is unable to continue with his dobutamine therapy secondary to nonsustained ventricular tachycardia.  At this time, we will transfer the patient to the Intensive Care Unit for titration of the Primacor therapy.  We will also increase his Lasix to 80 mg IV q.d.  We will increase his amiodarone to 400 mg daily.  We will also continue with his Coumadin therapy.  As stated previously, we will discontinue vasodilator therapy starting with the Isordil.
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DESCRIPTION: Right heart catheterization.   Refractory CHF to maximum medical therapy.

surgery, chf, cardiac, catheterization, swan-ganz, heart catheterization, internal jugular, pulmonary artery, heart, jugular, cannulate, vascular, needle, pulmonary, therapy

The situation involves a surgical procedure, specifically a right heart catheterization for a patient with refractory congestive heart failure (CHF) who is not responding to maximum medical therapy. The procedure is critical for assessing the patient's hemodynamics and guiding further treatment in the ICU. The patient's condition includes low perfusion and high systemic vascular resistance, which are serious indicators of heart failure severity. The necessity to adjust medications like Primacor and the patient's inability to tolerate standard treatments further indicate the high-stakes nature of the medical decision-making involved. The patient's life and health depend on precise medical interventions and continuous monitoring, particularly after experiencing nonsustained ventricular tachycardia, which is a potentially life-threatening condition.


Medical Specialty: Surgery
Sample Name: Excision - Soft Tissue Mass

PREOPERATIVE DIAGNOSIS: , Right flank subcutaneous mass.,POSTOPERATIVE DIAGNOSIS: , Right flank subcutaneous mass.,PROCEDURE PERFORMED: , Excision of soft tissue mass on the right flank.,ANESTHESIA: , Sedation with local.,INDICATIONS FOR PROCEDURE:,  This 54-year-old male was evaluated in the office with a large right flank mass.  He would like to have this removed.,DESCRIPTION OF PROCEDURE:,  Consent was obtained after all risks and benefits were described.  The patient was brought back into the operating room.  The aforementioned anesthesia was given.  Once the patient was properly anesthetized, the area was prepped and draped in the sterile fashion.  With the area properly prepped and draped, a needle was used to localize the area directly above the mass on the patient's right flank.  Then a #10 blade scalpel was used to make the incision approximately 4 cm to 5 cm in length just above the mass.  The incision was extended down using electrocautery.  The excision then had a Allis clamp placed on it and was retracted using sharp dissection and electrocautery was used to dissect the mass off the muscle.  The mass was sent off to Pathology for investigation.  Hemostasis maintained with electrocautery and then the subcutaneous fascia was closed using a #3-0 Vicryl suture in interrupted fashion and the skin was reapproximated using a #4-0 undyed Vicryl suture in a running subcuticular fashion.  The patient's wound was cleaned.  Steri-Strips were placed and sterile dressings were placed on top of this.  The patient tolerated the procedure well and will reevaluate in the office in one week's time.
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DESCRIPTION: Excision of soft tissue mass on the right flank.  This 54-year-old male was evaluated in the office with a large right flank mass.  He would like to have this removed.

surgery, electrocautery, soft tissue mass, subcutaneous, excision

The situation involves a surgical procedure to excise a soft tissue mass on a patient's right flank. Given that it is a planned and common surgical procedure with local anesthesia and sedation, where the mass will be sent for pathology, this can be regarded as a relatively routine medical procedure with standard risks associated with surgery. While there is always a degree of seriousness in any surgical procedure due to anesthesia involvement and potential complications, this specific scenario does not involve life-threatening or highly complex issues, thus making it low-stakes in the context of surgical procedures.


Medical Specialty: Surgery
Sample Name: Bronchoscopy - 2

INDICATIONS FOR PROCEDURE:,  Persistent cough productive of sputum requiring repeated courses of oral antibiotics over the last six weeks in a patient who is a recipient of a bone marrow transplant with end-stage chemotherapy and radiation-induced pulmonary fibrosis.,PREMEDICATION:,1.  Demerol 50 mg.,2.  Phenergan 25 mg.,3.  Atropine 0.6 mg IM.,4.  Nebulized 4% lidocaine followed by nasal insufflation of lidocaine through the right naris and topical 4% lidocaine gel through the right naris, 4 mg of Versed was given at the start of the procedure and another 1 mg shortly after traversing the cords.,PROCEDURE DETAILS:,  With the patient breathing oxygen by nasal cannula, being monitored by noninvasive blood pressure cuff and continuous pulse oximetry, the Olympus bronchoscope was introduced through the right naris to the level of the cords.  The cords move normally with phonation and ventilation.  Two times 2 mL of 1% lidocaine were instilled on the cords and the cords were traversed.  Further 2 mL of 1% lidocaine was instilled in the trachea just distal to the cords, at mid trachea above the carina, and on the right, and on the left mainstem bronchus.  Scope was then introduced on to the left where immediately some hyperemia of the mucosa was noted.  Upper lobe and lingula were unremarkable.  There appeared to be some narrowing or tenting of the left lower lobe bronchus such that after inspection of the superior segment, one almost had to pop the bronchoscope around to go down the left mainstem.  This had been a change from the prior bronchoscopy of unclear significance.  Distal to this, there was no hyperemia or inspissated mucus or mucoid secretions or signs of infection.  The scope was wedged in the left lower lobe posterior basal segment and a BAL was done with good returns, which were faintly hemorrhagic.  The scope was then removed, re-introduced up to the right upper lobe, middle lobe, superior segment, right lower, anterior lateral, and posterior basal subsegments were all evaluated and unremarkable.  The scope was withdrawn.  The patient's saturation remained 93%-95% throughout the procedure.  Blood pressure was 103/62.  Heart rate at the end of the procedure was about 100.  The patient tolerated the procedure well.  Samples were sent as follows.  Washings for AFB, Gram-stain Nocardia, Aspergillus, and routine culture.  Lavage for AFB, Gram-stain Nocardia, Aspergillus, cell count with differential, cytology, viral mycoplasma, and Chlamydia culture, GMS staining, RSV by antigen, and Legionella and Chlamydia culture.
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DESCRIPTION: Bronchoscopy for persistent cough productive of sputum requiring repeated courses of oral antibiotics over the last six weeks in a patient who is a recipient of a bone marrow transplant with end-stage chemotherapy and radiation-induced pulmonary fibrosis.

surgery, cough, bronchoscopy, olympus, bronchoscope, nasal insufflation, oral antibiotics, pulse oximetry, sputum, ventilation, antibiotics, nocardia, aspergillus, chlamydia, atropine, lidocaine, cords, topical,

This medical situation involves a bronchoscopy in a patient who has undergone a bone marrow transplant and now presents with respiratory issues in the context of significant pre-existing conditions, including chemotherapy and radiation-induced pulmonary fibrosis. The patient has a persistent cough and infection risk, requiring this invasive diagnostic procedure. The stakes are high because the patient is immunocompromised, increasing the risk of complications from both the procedure and any underlying infections. Additionally, findings from the bronchoscopy can significantly impact treatment decisions and patient outcomes.


Medical Specialty: Orthopedic
Sample Name: MRI Shoulder - 3

EXAM:,MRI RIGHT SHOULDER,CLINICAL:, A 32-year-old male with shoulder pain.,FINDINGS:,This is a second opinion interpretation of the examination performed on 02/16/06.,Normal supraspinatus tendon without surface fraying, gap or fiber retraction and there is no muscular atrophy.,Normal infraspinatus and subscapularis tendons.,Normal long biceps tendon within the bicipital groove. There is no subluxation of the tendon under the transverse humeral ligament and the intracapsular portion of the tendon is normal.,Normal humeral head without fracture or subluxation.,There is myxoid degeneration within the superior labrum (oblique coronal images #47-48), but there is no discrete tear. The remaining portions of the labrum are normal without osseous Bankart lesion.,Normal superior, middle and inferior glenohumeral ligaments.,There is a persistent os acromiale, and there is minimal reactive marrow edema on both sides of the synchondrosis, suggesting that there may be instability (axial images #3 and 4). There is no diastasis of the acromioclavicular joint itself. There is mild narrowing of the subacromial space secondary to the os acromiale, in the appropriate clinical setting, this may be acting as an impinging lesion (sagittal images #56-59).,Normal coracoacromial, coracohumeral and coracoclavicular ligaments.,There are no effusions or masses.,IMPRESSION:,Changes in the superior labrum compatible with degeneration without a discrete surfacing tear.,There is a persistent os acromiale, and there is reactive marrow edema on both sides of the synchondrosis suggesting instability. There is also mild narrowing of the subacromial space secondary to the os acromiale. This may be acting as an impinging lesion in the appropriate clinical setting.,There is no evidence of a rotator cuff tear.
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DESCRIPTION: A 32-year-old male with shoulder pain.

A 32-year-old male with shoulder pain.

orthopedic, impinging lesion, os acromiale, shoulder, tendon, acromiale, osseous

The MRI findings for the 32-year-old male show mostly normal results with some notable but not critical issues. These include myxoid degeneration in the superior labrum, reactive marrow edema suggesting possible instability due to a persistent os acromiale, and mild narrowing of the subacromial space. While these findings may contribute to pain or potential shoulder dysfunction, they do not indicate an immediate or severe threat to the patient's health. The absence of a rotator cuff tear and other major abnormalities suggests a more managed, rather than emergent, situation. The stakes would be higher if the findings indicated severe tears, fractures, or other critical conditions. Therefore, this situation is relatively standard and not high-stakes unless it significantly affects the patient's quality of life or requires urgent intervention.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Bunions and Calluses

S -, A 60-year-old female presents today for care of painful calluses and benign lesions.,O -, On examination, the patient has bilateral bunions at the first metatarsophalangeal joint.  She states that they do not hurt.  No pain appears to be produced by active or passive range of motion or palpation and direct pressure of the first metatarsophalangeal joint bilaterally.  The patient has a bilateral pinch callus on the medial aspect of both great toes and there are calluses along the medial aspect of the right foot.  She has a small intractable plantar keratoma, plantar to her left second metatarsal head, which measures 0.5 cm in diameter.  This is a central plug.  She also has a very, very painful lesion plantar to her right fourth metatarsal head which measures 3.1 x 1.8 cm in diameter.  This is a hyperkeratotic lesion that extends deep into the tissue with interrupted skin lines.,A - ,1.  Bilateral bunions.,
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DESCRIPTION: A 60-year-old female presents today for care of painful calluses and benign lesions.

soap / chart / progress notes, painful calluses, hibiclens, scrubbed, ointment and absorbent, heloma durum, plantar aspect, minimal hemostasis, neosporin ointment, absorbent dressing, benign lesions, metatarsophalangeal, bunions, calluses, plantar,

The situation involves a 60-year-old female patient presenting with painful calluses and benign lesions, along with bilateral bunions. While the presence of painful and large calluses can cause significant discomfort and impact quality of life, these conditions are typically not life-threatening or urgent unless they lead to complications such as infections. Therefore, while it is important to address the patient's pain and provide treatment to improve her comfort and mobility, the overall scenario does not present a high-stakes medical emergency.


Medical Specialty: ENT - Otolaryngology
Sample Name: Endoscopic Sinus Surgery

PREOPERATIVE DIAGNOSIS:,1.  Left chronic anterior and posterior ethmoiditis.,2.  Left chronic maxillary sinusitis with polyps.,3.  Left inferior turbinate hypertrophy.,4.  Right anterior and posterior chronic ethmoiditis.,5.  Right chronic maxillary sinusitis with polyps.,6.  Right chronic inferior turbinate hypertrophic.,7.  Intranasal deformity causing nasal obstruction due to septal deviation.,POSTOPERATIVE DIAGNOSIS:,1.  Left chronic anterior and posterior ethmoiditis.,2.  Left chronic maxillary sinusitis with polyps.,3.  Left inferior turbinate hypertrophy.,4.  Right anterior and posterior chronic ethmoiditis.,5.  Right chronic maxillary sinusitis with polyps.,6.  Right chronic inferior turbinate hypertrophic.,7.  Intranasal deformity causing nasal obstruction due to septal deviation.,NAME OF OPERATION: , Bilateral endoscopic sinus surgery, including left anterior and posterior ethmoidectomy, left maxillary antrostomy with polyp removal, left inferior partial turbinectomy, right anterior and posterior ethmoidectomy, right maxillary antrostomy and polyp removal, right partial inferior turbinectomy, and septoplasty.,ANESTHESIA:,  General endotracheal.,ESTIMATED BLOOD LOSS: , Approximately 20 cc.,HISTORY OF PRESENT ILLNESS: , The patient is a 55-year-old female who has had chronic nasal obstruction secondary to nasal polyps and chronic sinusitis.  She also has a septal deviation mid posterior to the left compromising greater than 70% of her nasal airway.,PROCEDURE:  ,The patient was brought to the operating room and placed in the supine position.  After adequate endotracheal anesthesia was obtained, the skin was prepped and draped in sterile fashion.  Lidocaine 1% with 1:100,000 epinephrine was injected into the region of the anterior portion of the nasal septum.  Approximately 10 cc total was used.,A #15 blade and the Freer elevator were used to help make a standard hemitransfixion incision.  A mucoperichondrial flap was carefully elevated, and the junction with the cartilaginous bony septum was separated with the Freer elevator.  The bony deflection was removed using Jansen-Middleton forceps.  The cartilaginous deflection was created by freeing up the inferior attachments to the cartilaginous septum, placing it more on the midline maxillary crest.  The initial incision was placed in its anatomical position and secured with a 4-0 nylon suture for stabilization effect.,Attention then was directed toward the left side.  Lidocaine 1% with 1:100,000 epinephrine was injected in the region of the anterior portion of the left middle turbinate and uncinate process and polyps.  Approximately 10 cc total was used.  The polyps were removed using the Richards essential shaver to help identify the middle turbinate and uncinate process better.  The uncinate process was removed systematically superiorly to inferiorly with back-biting forceps.  Next, the maxillary antrostomy was identified and expanded with the back-biting forceps and showed polypoid accumulation in the mucosal disease on its opening site.  The sinus linings were edematous but did not have any polyps in the inferior, lateral, or superior aspects.,The anterior and posterior ethmoid air cells were entered primarily and dissected with the Richards essential shaver followed by the use of a 30-degree endoscope and up-biting forceps for the superior and lateral dissection.  Bright mucosal disease and small polypoid accumulations were noted through the sinuses also.  The inferior turbinates had some polypoid changes on them also and showed marked mucosal irritation and hypertrophy.  The mucosal polypoid accumulations were cleared using the Richards essential shaver.  The turbinate was partially resected from mucosally but with good shape to it.  It was not desirable to remove it in its entirety.  Any obvious bleeding points along the edge were controlled with the suction Bovie apparatus.,The same procedure and findings were noted on the right side with 1% lidocaine with 1:100,000 epinephrine injected into the anterior portion of the right middle turbinate, polyps, and uncinate process; 10 cc total were used.  The polyps were removed.  The Richards essential shaver was used to allow better exposure of the uncinate process.  The uncinate process was removed superiorly to inferiorly with back-biting side-biting forceps.,Next, a maxillary antrostomy was identified and expanded with the back-biting and side-biting forceps and showed all plate accumulations there also.  The anterior and posterior ethmoid air cells were then entered primarily and dissected with Richards essential shaver followed by the use of the 30-degree scope and up-biting forceps for the superior and lateral resection.  The inferior turbinates showed mucosal disease, polypoid accumulations, and changes.  These were removed using the Richards essential shaver followed by a submucosal resection of the hypertrophied portion of the turbinate.,Any obvious bleeding points were controlled with the suction Bovie apparatus.  A thorough irrigation was then carried out in the nasal cavity, and Gelfilm packing was used to coat the linings in the middle meatal regions.  The patient tolerated the procedure well and returned to the recovery room in stable condition.
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DESCRIPTION: Ethmoidectomy, antrostomy with polyp removal, turbinectomy, and septoplasty.

The situation involves a detailed surgical procedure, specifically an endoscopic sinus surgery, which is inherently associated with some risks and complexities but is generally considered a routine procedure in the field of otolaryngology. The stakes are moderate because while complications can occur, they are not exceedingly common, and the outcomes are generally good when performed by experienced practitioners. Additionally, the fact that the patient tolerated the procedure well indicates that, in this case, the stakes were managed effectively.


Medical Specialty: Surgery
Sample Name: Colonoscopy - 7

PROCEDURE:,  Colonoscopy.,PREOPERATIVE DIAGNOSIS: , Follow up adenomas.,POSTOPERATIVE DIAGNOSES:,1.  Two colon polyps, removed.,2.  Small internal hemorrhoids.,3.  Otherwise normal examination of cecum.,MEDICATIONS: , Fentanyl 150 mcg and Versed 7 mg slow IV push.,INDICATIONS: , This is a 60-year-old white female with a history of adenomas.  She does have irregular bowel habits.,FINDINGS: , The patient was placed in the left lateral decubitus position and the above medications were administered.  The colonoscope was advanced to the cecum as identified by the ileocecal valve, appendiceal orifice, and blind pouch.  The colonoscope was slowly withdrawn and a careful examination of the colonic mucosa was made, including a retroflexed view of the rectum.  There was a 4 mm descending colon polyp, which was removed with jumbo forceps, and sent for histology in bottle one.  There was a 10 mm pale, flat polyp in the distal rectum, which was removed with jumbo forceps, and sent for histology in bottle 2.  There were small internal hemorrhoids.  The remainder of the examination was normal to the cecum.  The patient tolerated the procedure well without complication.,IMPRESSION:,1.  Two colon polyps, removed.,2.  Small internal hemorrhoids.,3.  Otherwise normal examination to cecum.,PLAN: , I will await the results of the colon polyp histology.  The patient was told the importance of daily fiber.
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DESCRIPTION: Patient with history of adenomas and irregular bowel habits.

surgery, colon polyps, internal hemorrhoids, rectum, irregular bowel habits, colon polyps removed, irregular bowel, bowel habits, polyps removed, bowel, habits, colonoscope, hemorrhoids, cecum, forceps, polyps, colonoscopy, adenomas,

The procedure described here is a colonoscopy, which is a routine medical diagnostic procedure often used to screen for colorectal cancer or investigate intestinal symptoms. The report indicates that the procedure went smoothly, with two polyps removed and no complications. While the histology results for the colon polyps are awaited to rule out any serious conditions like cancer, the situation is relatively under control given the patient's history and the nature of the findings. Therefore, it is not extremely high-stakes, although there is some importance due to the potential implications of the histology results.


Medical Specialty: Surgery
Sample Name: Suction, Dilation, & Curettage

PREOPERATIVE DIAGNOSIS: , Missed abortion.,POSTOPERATIVE DIAGNOSIS:  ,Missed abortion.,PROCEDURE PERFORMED: , Suction, dilation, and curettage.,ANESTHESIA: , Spinal.,ESTIMATED BLOOD LOSS:,  50 mL.,COMPLICATIONS: , None.,FINDINGS: , Products of conception consistent with a 6-week intrauterine pregnancy.,INDICATIONS: , The patient is a 28-year-old gravida 4, para 3 female at 13 weeks by her last menstrual period and 6 weeks by an ultrasound today in the emergency room who presents with heavy bleeding starting today.  A workup done in the emergency room revealed a beta-quant level of 1931 and an ultrasound showing an intrauterine pregnancy with a crown-rump length consistent with a 6-week and 2-day pregnancy.  No heart tones were visible.  On examination in the emergency room, a moderate amount of bleeding was noted.,Additionally, the cervix was noted to be 1 cm dilated.  These findings were discussed with the patient and options including surgical management via dilation and curettage versus management with misoprostol versus expected management were discussed with the patient.  After discussion of these options, the patient opted for a suction, dilation, and curettage.  The patient was described to the patient in detail including risks of infection, bleeding, injury to surrounding organs including risk of perforation.  Informed consent was obtained prior to proceeding with the procedure.,PROCEDURE NOTE:  ,The patient was taken to the operating room where spinal anesthesia was administered without difficulty.  The patient was prepped and draped in usual sterile fashion in lithotomy position.  A weighted speculum was placed.  The anterior lip of the cervix was grasped with a single tooth tenaculum.  At this time, a 7-mm suction curettage was advanced into the uterine cavity without difficulty and was used to suction contents of the uterus.  Following removal of the products of conception, a sharp curette was advanced into the uterine cavity and was used to scrape the four walls of the uterus until a gritty texture was noted.  At this time, the suction curette was advanced one additional time to suction any remaining products.  All instruments were removed.  Hemostasis was visualized.  The patient was stable at the completion of the procedure.  Sponge, lap, and instrument counts were correct.
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DESCRIPTION: Missed abortion.  Suction, dilation, and curettage.

surgery, missed abortion, intrauterine pregnancy, dilation, curettage, suction, intrauterine

This medical scenario involves surgical management of a missed abortion, specifically through suction, dilation, and curettage. The procedure itself is relatively common and straightforward, with no reported complications in this case, which would suggest a moderate-stakes situation. However, it remains a surgical intervention, with inherent risks that necessitate caution and expertise. Additionally, the emotional and psychological impact on the patient due to the nature of the diagnosis (missed abortion) increases the stakes from an emotional wellbeing perspective. Given no complications, reported stable patient condition, and successful procedure, this is a moderate-stakes situation.


Medical Specialty: Consult - History and Phy.
Sample Name: Urology Consut - 1

CHIEF COMPLAINT:,
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DESCRIPTION: Blood in urine - Transitional cell cancer of the bladder.

The presence of blood in urine could indicate a severe underlying condition, especially when connected with a diagnosis of transitional cell cancer of the bladder. This is a high-stakes medical situation as it involves cancer, which is a life-threatening disease requiring immediate and intensive medical management.


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

Medical Specialty: General Medicine
Sample Name: Gen Med SOAP - 11

SUBJECTIVE:,  The patient has recently had an admission for pneumonia with positive blood count.  She was treated with IV antibiotics and p.o. antibiotics; she improved on that.  She was at home and doing quite well for approximately 10 to 12 days when she came to the ER with a temperature of 102.  She was found to have strep.  She was treated with penicillin and sent home.  She returned about 8 o'clock after vomiting and a probable seizure.  Temperature was 104.5; she was lethargic after that.  She had an LP, which was unremarkable.  She had blood cultures, which have not grown anything.  The CSF has not grown anything at this point.,PHYSICAL EXAMINATION:,  She is alert, recovering from anesthesia.  Head, eyes, ears, nose and throat are unremarkable.  Chest is clear to auscultation and percussion.  Abdomen is soft.  Extremities are unremarkable.,LAB STUDIES: , White count in the emergency room was 9.8 with a slight shift.  CSF glucose was 68, protein was 16, and there were no cells.  The Gram-stain was unremarkable.,ASSESSMENT: , I feel that this patient has a febrile seizure.,PLAN: , My plan is to readmit the patient to control her temperature and assess her white count.  I am going to observe her overnight.
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DESCRIPTION: The patient has recently had an admission for pneumonia with positive blood count.  She returned after vomiting and a probable seizure.

general medicine, antibiotics, febrile seizure, temperature, blood count, white count, pneumonia, seizure,

The patient's condition involves a high fever, recent seizure, and a past diagnosis of pneumonia, indicating a potentially serious medical situation. While the current assessment suggests a febrile seizure, the involvement of previous infections and a seizure warrants close monitoring. The decision to readmit the patient for observation and temperature control highlights the need for careful management. However, there is no immediate life-threatening issue identified, such as meningitis or severe infection, according to the examination and lab results, which were largely unremarkable. The stakes are moderate given the circumstances.


Medical Specialty: Nephrology
Sample Name: Internal Jugular Vein Catheter Insertion

PREOPERATIVE DIAGNOSES:,1.  Acute on chronic renal failure.,2.  Uremia.,POSTOPERATIVE DIAGNOSES:,1.  Acute on chronic renal failure.,2.  Uremia.,PROCEDURE PERFORMED:  ,Insertion of a right internal jugular vein hemodialysis catheter.,ANESTHESIA: , 1% local lidocaine.,BLOOD LOSS: , Less than 5 cc.,COMPLICATIONS: , None.,HISTORY: , The patient is a 74-year-old Caucasian male who presents via direct admission for acute on chronic renal failure with uremia.  The patient incidentally was in a car accident ten days ago and has been feeling pretty awful since that time.  He is slightly short of breath with mild difficulty in breathing.  A pre-procedure x-ray was obtained, which showed no pneumothorax.  He did have a significant right pleural effusion and a mild left pleural effusion.  We decided to insert the catheter on the right side.,PROCEDURE:  ,The patient was prepped and draped in the usual sterile fashion.  1% lidocaine was used to anesthetize the area two fingerbreadths above the clavicle just posterior to the right sternocleidomastoid muscle and below the external jugular vein.  Using the same anesthetic needle, the right internal jugular vein was used to cannulate with good venous blood return.  The tract was noted.,The needle was removed and a second #18 gauge thin-walled needle was used along same tract to cannulate the right internal jugular vein also without difficulty and good venous blood return.  The syringe was removed and a Seldinger guidewire was inserted through the needle to cannulate the vein also without difficulty.  The needle was removed and an #11 blade was used to make a small skin incision provided skin and vein dilators were used.  The circle-C 8-inch hemodialysis catheter was then inserted over the guidewire without difficulty.  The guidewire was removed.  Both of the ports were aspirated venous blood without difficulty and both flushed also without difficulty.  The ports were flushed with injectable normal saline secondary to the patient going for dialysis today.  Thus, he will not need heparinization of the lines.  Again, he tolerated the procedure well.  A postoperative x-ray would be obtained to check catheter placement and rule out pneumothorax.
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DESCRIPTION: Acute on chronic renal failure and uremia.  Insertion of a right internal jugular vein hemodialysis catheter.

nephrology, uremia, internal jugular vein hemodialysis catheter, pneumothorax, jugular vein, dialysis, chronic renal failure, internal jugular vein, pleural effusion, hemodialysis catheter, renal failure, cannulate, guidewire, insertion, jugular, catheter, hemodialysis, vein

The situation involves a medical procedure for a patient with acute on chronic renal failure and uremia. Insertion of a jugular vein catheter for hemodialysis is generally a common and straightforward procedure for patients in need of urgent dialysis. The document indicates no complications during the procedure and minimal blood loss, suggesting it was successful and routine in nature. While the patient's condition is medically significant, and procedures involving major veins carry some inherent risks, the procedure itself is low-risk and typical in such medical scenarios. Thus, while the procedure was necessary to address a serious medical condition, routine catheter insertion does not represent a particularly high-stakes scenario in the context of medical procedures.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Cardiac Cath & Coronary Angiography

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

The situation involves a serious and potentially life-threatening cardiac procedure. The patient has a history of atherosclerotic coronary artery disease and a previous ST elevation myocardial infarction (MI), conditions that are high-stakes due to their potential to lead to serious health consequences or death. The procedure detailed is invasive and directly addresses severe coronary artery conditions, highlighting the high stakes nature due to possible complications or urgent interventions that could arise. Successful stent placement indicated that a critical blockage was resolved, but the overall severity and implications for the patient's heart health contribute to the high-stakes rating.


Medical Specialty: Endocrinology
Sample Name: Thyroidectomy - 1

PREOPERATIVE DIAGNOSIS: , Thyroid goiter.,POSTOPERATIVE DIAGNOSIS:  ,Thyroid goiter.,PROCEDURE PERFORMED: , Total thyroidectomy.,ANESTHESIA:,1.  General endotracheal anesthesia.,2.  9 cc of 1% lidocaine with 1:100,000 epinephrine.,COMPLICATIONS:,  None.,PATHOLOGY: , Thyroid.,INDICATIONS:  ,The patient is a female with a history of Graves disease.  Suppression was attempted, however, unsuccessful.  She presents today with her thyroid goiter.  A thyroidectomy was indicated at this time secondary to the patient's chronic condition.  Indications, alternatives, risks, consequences, benefits, and details of the procedure including specifically the risk of recurrent laryngeal nerve paresis or paralysis or vocal cord dysfunction and possible trach were discussed with the patient in detail.  She agreed to proceed.  A full informed consent was obtained.,PROCEDURE: , The patient presented to ABCD General Hospital on 09/04/2003 with the history was reviewed and physical examinations was evaluated.  The patient was brought by the Department of Anesthesiology, brought back to surgical suite and given IV access and general endotracheal anesthesia.  A 9 cc of 1% lidocaine with 1:100,000 of epinephrine was infiltrated into the area of pre-demarcated above the suprasternal notch.  Time is allowed for full hemostasis to be achieved.  The patient was then prepped and draped in the normal sterile fashion.  A #10 blade was then utilized to make an incision in the pre-demarcated and anesthetized area.  Unipolar electrocautery was utilized for hemostasis.  Finger dissection was carried out in the superior and inferior planes.  Platysma was identified and dissected and a subplatysmal plane was created in the superior and inferior, medial and lateral directions using hemostat, Metzenbaum, and blunt dissection.  The strap muscles were identified.  The midline raphe was not easily identifiable at this time.  An incision was made through what appeared to be in the midline raphe and dissection was carried down to the thyroid.  Sternohyoid and sternothyroid muscles were identified and separated on the patient's right side and then subsequently on the left side.  It was noted at this time that the thyroid lobule on the right side is a bi-lobule.  Kitner blunt dissection was utilized to bluntly dissect the overlying thyroid fascia as well as strap muscles off the thyroid, force in the lateral direction.  This was carried down to the inferior and superior areas.  The superior pole of the right lobule was then identified.  A hemostat was placed in the cricothyroid groove and a Kitner was placed in this area.  A second Kitner was placed on lateral aspect of the superior pole and the superior pole of the right thyroid was retracted inferiorly.  Careful dissection was then carried out in a very meticulous fashion in the superior lobe and identified the appropriate vessels and cauterized with bipolar or ligated with the suture ligature.  This was carried out until the superior pole was identified.  Careful attention was made to avoid nerve injury in this area.  Dissection was then carried down again bluntly separating the inferior and superior lobes.  The bilobed right thyroid was then retracted medially.  The recurrent laryngeal nerve was then identified and tracked to its insertion.  The overlying vessels of the middle thyroid vein as well as the associated structures were then identified and great attention was made to perform a right careful meticulous dissection to remove the fascial attachments superficial to the recurrent laryngeal nerve off the thyroid.  When it was completed, this lobule was then removed from Berry's ligament.  There was noted to be no isthmus at this time and the entire right lobule was then sent to the Pathology for further evaluation.  Attention was then diverted to the patient's left side.  In a similar fashion, the sternohyoid and sternothyroid muscles were already separated.  Army-Navy as well as femoral retractors were utilized to lateralize the appropriate musculature.  The middle thyroid vein was identified.  Blunt dissection was carried out laterally to superiorly once again.  A hemostat was utilized to make an opening in the cricothyroid groove and a Kitner was then placed in this area.  Another Kitner was placed on the lateral aspect of the superior lobe of the left thyroid and retracted inferiorly.  Once again, a careful meticulous dissection was utilized to identify the appropriate structures in the superior pole of the left thyroid and suture ligature as well as bipolar cautery was utilized for hemostasis.  Once again, a careful attention was made not to injure the nerve in this area.  The superior pole was then freed appropriately and blunt dissection was carried down to lateral and inferior aspects.  The inferior aspect was then identified.  The inferior thyroid artery and vein were then identified and ligated.  The left thyroid was then medialized and the recurrent laryngeal nerve has been identified.  A careful dissection was then carried out to remove the fascial attachments superficial to the recurrent laryngeal nerve on the side as close to the thyroid gland as possible.  The thyroid was then removed from the Berry's ligament and it was then sent to Pathology for further evaluation.  Evaluation of the visceral space did not reveal any bleeding at this time.  This was irrigated and pinpoint areas were bipolored as necessary.  Surgicel was then placed bilaterally.  The strap muscles as well as the appropriate fascial attachments were then approximated with a #3-0 Vicryl suture in the midline.  The platysma was identified and approximated with a #4-0 Vicryl suture and the subdermal plane was approximated with a #4-0 Vicryl suture.  A running suture consisting of #5-0 Prolene suture was then placed and fast absorbing #6-0 was then placed in a running fashion.  Steri-Strips, Tincoban, bacitracin and a pressure gauze was then placed.  The patient was then admitted for further evaluation and supportive care.  The patient tolerated the procedure well.  The patient was transferred to Postanesthesia Care Unit in stable condition.
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DESCRIPTION: Total thyroidectomy.  The patient is a female with a history of Graves disease.  Suppression was attempted, however, unsuccessful.  She presents today with her thyroid goiter.

endocrinology, thyroid goiter, graves disease, thyroidectomy, total thyroidectomy, dissection, superior, kitner

The procedure described is a total thyroidectomy, which is a significant surgical intervention due to the complexities involved and the potential for serious postoperative complications. The risk of nerve damage and associated complications, such as vocal cord dysfunction, adds to the stakes of the situation. Additionally, thyroid removal can have significant long-term impacts on a patient's health, necessitating lifelong hormone replacement therapy. However, in this specific case, the operation was completed with no immediate complications and the patient tolerated the procedure well, which somewhat reduces the immediate stakes. Despite the successful procedure, the inherent risks and the need for careful postoperative management and monitoring make this a relatively high-stakes scenario.


Medical Specialty: Orthopedic
Sample Name: Total Knee Arthroplasty

PREOPERATIVE DIAGNOSIS:,  Degenerative osteoarthritis, right knee.,POSTOPERATIVE DIAGNOSIS: , Degenerative osteoarthritis, right knee.,PROCEDURE PERFORMED: ,Right knee total arthroplasty.,ANESTHESIA: , The procedure was done under a subarachnoid block anesthetic in the supine position with a tourniquet utilized.,TOTAL TOURNIQUET TIME: , Approximately 90 minutes.,SPECIFICATIONS: , The entire procedure is done in the inpatient operating suite in the Room #1 at ABCD General Hospital.  The following sizes of NexGen system were utilized:  E on right femur, cemented; 5 tibial stem tray with a 10 mm polyethylene insert, and a 32 mm patellar button.,HISTORY AND GROSS FINDINGS: , This is a 58-year-old white female suffering increasing right knee pain for number of years prior to surgical intervention.  She was completely refractory to conservative outpatient therapy.  She had undergone two knee arthroscopies in the years preceding this.  They were performed by myself.  She ultimately failed this treatment and developed a collapsing-type valgus degenerative osteoarthritis with complete collapse and ware of the lateral compartment and degenerative changes noted to the femoral sulcus that were proved live.  Medial compartment had minor changes present.  There was no contracture of the lateral collateral ligament, but instead mild laxity on both sides.  There was no significant flexion contracture preoperatively.,OPERATIVE PROCEDURE:  ,The patient was laid supine upon the operating table after receiving a subarachnoid block anesthetic by the Anesthesia Department.  Thigh tourniquet was placed upon the patient's right leg.  She was prepped and draped in the usual sterile manner.  The limb was elevated and exsanguinated and tourniquet placed 325 mmHg for the above noted time.  A straight incision was carried down through the skin and subcutaneous tissue.  Hemostasis was controlled with electrocoagulation.  Medial parapatellar arthrotomy was created and the knee cap was everted.  The ligaments were balanced.  A portion of the fat pad was removed and the ACL was completely removed.  Drill hole was made in the distal femur.  The size to an E, right.  Care was taken to make up for the severe loss of articular cartilage on the posterior condyle in the lateral side.  This was checked with the epicondylar abscess and with three degrees of external rotation, drill holes were made.  Intramedullary guide was then placed, pegged, and anterior cut carried out.  There was excellent resection.  It was flat.  Distal cutting guide was then placed in five degrees of valgus.  Appropriate cuts were carried out.  The standard cut was utilized.,The finishing guide for E was held with pins as well as screws.  Cutting was carried out posterior to anterior, then posterior chamfer and anterior chamfer, femoral sulcus cut was carried out and drill holes for pegs were made.  The cutting guide was then removed.  The bone was removed.  Excess bone was taken out posteriorly.  The posterior capsule was loosened up.  There were two different fabellas in the posterolateral compartment and they were loosened.  Posterolateral corner was then anchored with osteotome and was taken around the posterolateral corner.  An extramedullary tibial cutting guide was then placed, pinned, and held.  A cut was carried out parallel to the foot.  Hard copy ________ was obtained, deemed to be satisfactory after evening up the edges.  Trial range of motion was satisfactory.  It was necessary to perform a lateral retinacular release to the patella.  The patella was isolated.  Approximately 10 mm to 11 mm were reamed off.  The size to 32 mm button and drill hole guide was placed, impacted, and drilled.  Trial range of motion was satisfactory.  The tibial guide was then pinned.  Drill hole was placed, broached, and utilized.  Copious irrigation was carried out.  Methylmethacrylate was mixed and was sequentially placed from the femur to the tibia to the patella.  The implants were sequentially placed in tibia to femur to patella.  Once excess methylmethacrylate was removed and cured, 10 mm Poly was placed.  There was excellent ligament balancing.  A separate portal was utilized for subcutaneous drain.  Tourniquet was deflated and hemostasis was controlled with electrocoagulation.  Interrupted #1 Ethibond suture was utilized for parapatellar closure, running #1 Vicryl suture was utilized for overstitch.,Trial range of motion was satisfactory.  Interrupted #2-0 Vicryl was utilized for subcutaneous fat closure and skin staples were placed to the skin.  Adaptic, 4x4s, ABDs, and Webril were placed for compression dressing.  Digits were pink and warm with brawny pulses distally at the end of the case.  The patient was then transferred to PACU in apparent satisfactory condition.  Expected surgical prognosis on this patient is fair.
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DESCRIPTION: Right knee total arthroplasty.  Degenerative osteoarthritis, right knee.

orthopedic, arthroplasty, knee, degenerative osteoarthritis, subcutaneous, osteoarthritis, degenerative, tourniquet, drill,

The described situation pertains to a total knee arthroplasty procedure for a patient with degenerative osteoarthritis. While this is a common and routine orthopedic surgery, it involves significant surgical intervention and has inherent risks, such as infection, bleeding, and anesthesia complications. The patient underwent a complex procedure with multiple steps, suggesting moderate stakes in terms of potential impact on the patient's functionality and quality of life. However, this case does not present any unusual complications or rare conditions that would elevate it to higher stakes, such as life-threatening scenarios.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Coarctation of Aorta

HISTORY: , The patient is a 4-month-old who presented with respiratory distress and absent femoral pulses with subsequent evaluation including echocardiogram that demonstrated severe coarctation of the aorta with a peak gradient of 29 mmHg and associated dilated cardiomyopathy with fractional shortening of 16%.  A bicuspid aortic valve was also seen without insufficiency or stenosis.  The patient underwent cardiac catheterization for balloon angioplasty for coarctation of the aorta.,PROCEDURE:  ,After sedation and general endotracheal anesthesia, the patient was prepped and draped.  Cardiac catheterization was performed as outlined in the attached continuation sheets.  Vascular entry was by percutaneous technique, and the patient was heparinized.  Monitoring during the procedure included continuous surface ECG, continuous pulse oximetry, and cycled cuff blood pressures, in addition to intravascular pressures.,Using a percutaneous technique a 4-French 8 cm long double lumen central venous catheter was inserted in the left femoral vein and sutured into place.  There was good blood return from both the ports.,Using a 4-French sheath a 4-French wedge catheter was inserted into the right femoral vein and advanced through the right heart structures out to the branch of pulmonary arteries.  The atrial septum was not probe patent.,Using a 4-French sheath a 4-French marker pigtail catheter was inserted into the left femoral artery and advanced retrograde to the descending aorta ,ascending aorta and left ventricle.  A descending aortogram demonstrated discrete coarctation of the aorta approximately 8 mm distal to the origin of the left subclavian artery.  The transverse arch measured 5 mm.  Isthmus measured 4.7 mm and coarctation measured 2.9 x 1.8 mm at the descending aorta level.  The diaphragm measured 5.6 mm.  The pigtail catheter was exchanged for a wedge catheter, which was then directed into the right innominate artery.  This catheter was exchanged over a wire for a Tyshak mini 6 x 2 cm balloon catheter which was advanced across the coarctation and inflated with complete disappearance of discrete waist.  Pressure pull-back following angioplasty, however, demonstrated a residual of 15-20 mmHg gradient.  Repeat angiogram showed mild improvement in degree of aortic narrowing.  The angioplasty was then performed using a Tyshak mini 7 x 2 cm balloon catheter with complete disappearance of mild waist.  The pigtail catheter was then reintroduced for a pressure pull-back measurement and final angiogram.,Flows were calculated by the Fick technique using an assumed oxygen consumption.,Cineangiograms were obtained with injection in the descending aorta.,After angiography, two normal-appearing renal collecting systems were visualized.  The catheters and sheaths were removed and topical pressure applied for hemostasis.  The patient was returned to the pediatric intensive care unit in satisfactory condition.  There were no complications.,DISCUSSION: , Oxygen consumption was assumed to be normal.  Mixed venous saturation was low due to mild systemic arterial desaturation and anemia.  There is no evidence of significant intracardiac shunt.  Further the heart was desaturated due to VQ mismatch.,Phasic right-sided pressures were normal as was the right pulmonary artery capillary wedge pressure with the A-wave similar to the normal left ventricular end-diastolic pressure of 12 mmHg.  Left ventricular systolic pressure was mildly increased with a 60 mmHg systolic gradient into the ascending aorta and a 29 mmHg systolic gradient on pressure pull-back to the descending aorta.  The calculated flows were mildly increased.  Vascular resistances were normal.  A cineangiogram with contrast injection in the descending aorta showed a normal left aortic arch with normal origins of the brachiocephalic vessels.  There is discrete juxtaductal coarctation of the aorta.  Flow within the intercostal arteries was retrograde.  Following balloon angioplasty of coarctation of the aorta, there was slight fall in the mixed venous saturation and an increase in systemic arterial saturation as the fall in left ventricular systolic pressure from 99 mmHg to 92 mmHg.  There remained a 4 mmHg systolic gradient into the ascending aorta and 9 mmHg systolic gradient pressure pull-back to the descending aorta.  The calculated systemic flow fell to normal values.  Final angiogram with injection in the descending aorta demonstrated improved caliber of coarctation of the aorta with mild intimal irregularity and a small left lateral filling defect consistent with a small intimal tear in the region of the ductus arteriosus.  There is brisk flow in the descending aorta and appropriate flow in the intercostal arteries.  The narrowest diameter of the aorta measured 4.9 x 4.2 mm.,DIAGNOSES:  ,1.  Juxtaductal coarctation of the aorta.,2.  Dilated cardiomyopathy.,3.  Bicuspid aortic valve.,4.  Patent foramen ovale.,INTERVENTION: , Balloon dilation of coarctation of the aorta.,MANAGEMENT: , The case will be discussed at combined Cardiology and Cardiothoracic Surgery Case Conference.  The patient will be allowed to recover from the current intervention with the hopes of complete left ventricular function recovery.  The patient will undoubtedly require formal coarctation of the aorta repair surgically in 4-6 months.  The further cardiologic care will be directed by Dr. X.
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DESCRIPTION: Juxtaductal coarctation of the aorta, dilated cardiomyopathy, bicuspid aortic valve, patent foramen ovale.

cardiovascular / pulmonary, coarctation, juxtaductal, dilated cardiomyopathy, bicuspid aortic valve, patent foramen ovale, catheter was inserted, mmhg systolic gradient, mmhg systolic, systolic gradient, descending aorta, catheterization, mmhg, ventricular, aorta, aortic, foramen,

This case involves a 4-month-old infant with severe cardiovascular issues, including coarctation of the aorta, dilated cardiomyopathy, and a bicuspid aortic valve. The child underwent a high-stakes intervention, balloon angioplasty, and will require further surgical intervention in a few months. The conditions are life-threatening and require careful management and monitoring by a team of specialists. Given the age of the patient and the complexity of the conditions, the stakes are extremely high.


Medical Specialty: Surgery
Sample Name: Heart Catheterization, Ventriculography, & Angiography - 11

NAME OF PROCEDURES,1.  Selective coronary angiography.,2.  Left heart catheterization.,3.  Left ventriculography.,PROCEDURE IN DETAIL:  ,The right groin was sterilely prepped and draped in the usual fashion.  The area of the right coronary artery was anesthetized with 2% lidocaine and a 4-French sheath was placed.  Conscious sedation was obtained using a combination of Versed 1 mg and fentanyl 50 mcg.  A left #4, 4-French, Judkins catheter was placed and advanced through the ostium of the left main coronary artery.  Because of difficulty positioning the catheter, the catheter was removed and a 6-French sheath was placed and a 6-French #4 left Judkins catheter was placed.  This was advanced through the ostium of the left main coronary artery where selective angiograms were performed.  Following this, the 4-French right Judkins catheter was placed and angiograms of the right coronary were performed.  A pigtail catheter was placed and a left heart catheterization was performed, followed by a left ventriculogram.  The left heart pullback was performed.  The catheter was removed and a small injection of contrast was given to the sheath.  The sheath was removed over a wire and an Angio-Seal was placed.  There were no complications.  Total contrast media was 200 mL of Optiray 350.  Fluoroscopy time 5.3 minutes.  Total x-ray dose is 1783 mGy.,HEMODYNAMICS:  ,Rhythm is sinus throughout the procedure.  LV pressure of 155/22 mmHg, aortic pressure of 160/80 mmHg.  LV pullback demonstrates no gradient.,The right coronary artery is a nondominant vessel and free of disease.  This also gives rise to the conus branch and two RV free wall branches.  The left main has minor plaquing in the inferior aspect measuring no more than 10% to 15%.  This vessel then bifurcates into the LAD and circumflex.  The circumflex is a large caliber vessel and is dominant.  This vessel gives rise to a large first marginal artery, a moderate sized second marginal branch, and additionally gives rise to a large third marginal artery and the PDA.  There was a very eccentric and severe stenosis in the proximal circumflex measuring approximately 90% in severity.  The origin of the first marginal artery has a severe stenosis measuring approximately 90% in severity.  The distal circumflex has a 60% lesion just prior to the origin of the third marginal branch and PDA.,The proximal LAD is ectatic.  The LAD gives rise to a large first diagonal artery that has a 90% lesion in its origin and a subtotal occlusion midway down the diagonal.  Distal to the origin of this diagonal branch, there is another area of ectasia in the LAD, followed by an area of stenosis that in some views is approximately 50% in severity.,The left ventriculogram demonstrates hypokinesis of the distal half of the inferior wall.  The overall ejection fraction is preserved.  There is moderate dilatation of the aortic root.  The calculated ejection fraction is 63%.,IMPRESSION,1.  Left ventricular dysfunction as evidenced by increased left ventricular end diastolic pressure and hypokinesis of the distal inferior wall.,2.  Coronary artery disease with high-grade and complex lesion in the proximal portion of the dominant large circumflex coronary artery.  There is subtotal stenosis at the origin of the first obtuse marginal artery.,3.  A 60% stenosis in the distal circumflex.,4.  Ectasia of the proximal left anterior descending with 50% stenosis in the mid left anterior descending.,5.  Severe stenosis at the origin of the large diagonal artery and subtotal stenosis in the mid segment of this diagonal branch.
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DESCRIPTION: Selective coronary angiography, left heart catheterization, and left ventriculography.  Severe stenosis at the origin of the large diagonal artery and subtotal stenosis in the mid segment of this diagonal branch.

surgery, coronary angiography, catheterization, ventriculography, heart catheterization, coronary artery, stenosis, artery, angiography

The document describes a detailed surgical procedure involving heart catheterization and angiography, which are significant medical procedures typically performed to diagnose and evaluate heart conditions. The context indicates severe stenosis in multiple heart arteries, which can be life-threatening if not addressed promptly. These procedures are crucial for determining the appropriate treatment path, potentially involving further interventions like surgery or angioplasty. This situation requires precision and expertise to prevent complications, making it high-stakes in terms of patient health outcomes and potential impact.


Medical Specialty: General Medicine
Sample Name: Normal ROS Template

REVIEW OF SYSTEMS,GENERAL/CONSTITUTIONAL: , The patient denies fever, fatigue, weakness, weight gain or weight loss.,HEAD, EYES, EARS, NOSE AND THROAT:,  Eyes - The patient denies pain, redness, loss of vision, double or blurred vision, flashing lights or spots, dryness, the feeling that something is in the eye and denies wearing glasses.  Ears, nose, mouth and throat.  The patient denies ringing in the ears, loss of hearing, nosebleeds, loss of sense of smell, dry sinuses, sinusitis, post nasal drip, sore tongue, bleeding gums, sores in the mouth, loss of sense of taste, dry mouth, dentures or removable dental work, frequent sore throats, hoarseness or constant feeling of a need to clear the throat when nothing is there, waking up with acid or bitter fluid in the mouth or throat, food sticking in throat when swallows or painful swallowing.,CARDIOVASCULAR: , The patient denies chest pain, irregular heartbeats, sudden changes in heartbeat or palpitation, shortness of breath, difficulty breathing at night, swollen legs or feet, heart murmurs, high blood pressure, cramps in his legs with walking, pain in his feet or toes at night or varicose veins.,RESPIRATORY: , The patient denies chronic dry cough, coughing up blood, coughing  up mucus, waking at night coughing or choking, repeated pneumonias, wheezing or night sweats.,GASTROINTESTINAL: , The patient denies decreased appetite, nausea, vomiting, vomiting blood or coffee ground material, heartburn, regurgitation, frequent belching, stomach pain relieved by food, yellow jaundice, diarrhea, constipation, gas, blood in the stools, black tarry stools or hemorrhoids.,GENITOURINARY:  ,The patient denies difficult urination, pain or burning with urination, blood in the urine, cloudy or smoky urine, frequent need to urinate, urgency, needing to urinate frequently at night, inability to hold the urine, discharge from the penis, kidney stones, rash or ulcers, sexual difficulties, impotence or prostate trouble, no sexually transmitted diseases.,MUSCULOSKELETAL: , The patient denies arm, buttock, thigh or calf cramps.  No joint or muscle pain.  No muscle weakness or tenderness.  No joint swelling, neck pain, back pain or major orthopedic injuries.,SKIN AND BREASTS:  ,The patient denies easy bruising, skin redness, skin rash,  hives, sensitivity to sun exposure, tightness, nodules or bumps, hair loss, color changes in the hands or feet with cold, breast lump, breast pain or nipple discharge.,NEUROLOGIC: , The patient denies headache, dizziness, fainting, muscle spasm, loss of consciousness, sensitivity or pain in the hands and feet or memory loss.,PSYCHIATRIC:  ,The patient denies depression with thoughts of suicide, voices in ?? head telling ?? to do things and has not been seen for psychiatric counseling or treatment.,ENDOCRINE: , The patient denies intolerance to hot or cold temperature, flushing, fingernail changes, increased thirst, increased salt intake or decreased sexual desire.,HEMATOLOGIC/LYMPHATIC:  ,The patient denies anemia, bleeding tendency or clotting tendency.,ALLERGIC/IMMUNOLOGIC: , The patient denies rhinitis, asthma, skin sensitivity, latex allergies or sensitivity.
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DESCRIPTION: Normal review of systems template.  The patient denies fever, fatigue, weakness, weight gain or weight loss.

general medicine, cardiovascular, ears, eyes, gastrointestinal, head, nose, respiratory, review of systems, denies fever, blood, tongue, loss,

The scenario describes a standard 'Review of Systems' (ROS) in general medicine, where a patient is reporting no symptoms or issues across a number of systems (e.g., cardiovascular, respiratory, gastrointestinal). This information is often collected as part of routine checkups or assessments and is not indicative of an immediate or high-stakes medical situation. The absence of reported symptoms suggests there is no active medical emergency or condition requiring urgent intervention. Thus, it is standard practice and not high-stakes.