Medical Specialty: Gastroenterology
Sample Name: Postop Transanal Excision

PREOPERATIVE DIAGNOSIS: , Bleeding after transanal excision five days ago.,POSTOPERATIVE DIAGNOSIS: , Bleeding after transanal excision five days ago.,PROCEDURE:,  Exam under anesthesia with control of bleeding via cautery.,ANESTHESIA:,  General endotracheal.,INDICATION: , The patient is a 42-year-old gentleman who is five days out from transanal excision of a benign anterior base lesion.  He presents today with diarrhea and bleeding.  Digital exam reveals bright red blood on the finger.  He is for exam under anesthesia and control of hemorrhage at this time.,FINDINGS: , There was an ulcer where most of the polypoid lesion had been excised before.  In a near total fashion the wound had opened and again there was a raw ulcer surface in between the edges of the mucosa.  There were a few discrete sites of mild oozing, which were treated with cautery and #1 suture.  No other obvious bleeding was seen.,TECHNIQUE: , The patient was taken to the operating room and placed on the operative table in supine position.  After adequate general anesthesia was induced, the patient was then placed in modified prone position.  His buttocks were taped, prepped and draped in a sterile fashion.  The anterior rectal wall was exposed using a Parks anal retractor.  The entire wound was visualized with a few rotations of the retractor and a few sites along the edges were seen to be oozing and were touched up with cautery.  There was one spot in the corner that was oozing and this may have been from simply opening the retractor enough to see well.  This was controlled with a 3-0 Monocryl figure-of-eight suture.  At the completion, there was no bleeding, no oozing, it was completely dry, and we removed our retractor, and the patient was then turned and extubated and taken to the recovery room in stable condition.
---
DESCRIPTION: Bleeding after transanal excision five days ago.  Exam under anesthesia with control of bleeding via cautery.  The patient is a 42-year-old gentleman who is five days out from transanal excision of a benign anterior base lesion.  He presents today with diarrhea and bleeding.

gastroenterology, diarrhea, anterior base lesion, polypoid lesion, transanal excision, transanal, anesthesia, bleeding,

This situation involves post-operative complications following a transanal excision, specifically bleeding. While any post-operative bleeding is a concern, it was addressed with a relatively standard procedure involving examination under anesthesia and cautery. The intervention was successful, and the patient was stable afterwards. This suggests that while immediate attention was necessary, it was not an extreme emergency or high-stakes life-threatening situation.


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

Medical Specialty: Consult - History and Phy.
Sample Name: Renal Insufficiency - Consult

REASON FOR CONSULT:, Renal insufficiency.,HISTORY OF PRESENT ILLNESS:, A 48-year-old African-American male with a history of coronary artery disease, COPD, congestive heart failure with EF of 20%-25%, hypertension, renal insufficiency, and recurrent episodes of hypertensive emergency, admitted secondary to shortness of breath and productive cough. The patient denies any chest pain, palpitations, syncope, or fever. Denied any urinary disturbances, difficulty, burning micturition, hematuria, or back pain. Nephrology is consulted regarding renal insufficiency.,REVIEW OF SYSTEMS:, Reviewed entirely and negative except for HPI.,PAST MEDICAL HISTORY:, Hypertension, congestive heart failure with ejection fraction of 20%-25% in December 2005, COPD, mild diffuse coronary artery disease, and renal insufficiency.,ALLERGIES:, NO KNOWN DRUG ALLERGIES.,MEDICATIONS:, Clonidine 0.3 p.o. q.8, aspirin 325 daily, hydralazine 100 q.8, Lipitor 20 at bedtime, Toprol XL 100 daily.,FAMILY HISTORY:, Noncontributory.,SOCIAL HISTORY:, The patient denies any alcohol, IV drug abuse, tobacco, or any recreational drugs.,PHYSICAL EXAMINATION:,VITAL SIGNS: Blood pressure 180/110. Temperature 98.1. Pulse rate 60. Respiratory rate 23. O2 sat 95% on room air.,GENERAL: A 48-year-old African-American male in no acute distress.,HEENT: Pupils equal, round, and reactive to light and accommodation. No pallor or icterus.,NECK: No JVD, bruit, or lymphadenopathy.,HEART: S1 and S2, regular rate and rhythm, no murmurs, rubs, or gallops.,LUNGS: Clear. No wheezes or crackles.,ABDOMEN: Soft, nontender, nondistended, no organomegaly, bowel sounds present.,EXTREMITIES: No cyanosis, clubbing, or edema.,CNS: Exam is nonfocal.,LABS:, WBC 7, H and H 13 and 40, platelets 330, PT 12, PTT 26, CO2 20, BUN 27, creatinine 3.1, cholesterol 174, BNP 973, troponin 0.18. Previous creatinine levels were 2.7 in December. Urine drug screen positive for cocaine.,ASSESSMENT:, A 48-year-old African-American male with a history of coronary artery disease, congestive heart failure, COPD, hypertension, and renal insufficiency with:,1. Hypertensive emergency.,2. Acute on chronic renal failure.,3. Urine drug screen positive.,4. Question CHF versus COPD exacerbation.,PLAN:,1. Most likely, renal insufficiency is a chronic problem. Hypertensive etiology worsened by the patient's chronic cocaine abuse.,2. Control blood pressure with medications as indicated. Hypertensive emergency most likely related to cocaine drug abuse.,Thank you for this consult. We will continue to follow the patient with you.
---
DESCRIPTION: Patient with a history of coronary artery disease, congestive heart failure, COPD, hypertension, and renal insufficiency.

This case is high-stakes due to the combination of multiple chronic conditions, including coronary artery disease, congestive heart failure with a significantly reduced ejection fraction, COPD, and renal insufficiency, compounded by a hypertensive emergency and cocaine use. The patient's complex medical history and current issues, such as acute on chronic renal failure and potential exacerbations of heart or lung conditions, necessitate careful management to prevent further deterioration or life-threatening events.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Orthopedic
Sample Name: MRI C3 - Cord Compression.

CC:, Left third digit numbness and wrist pain.,HX: ,This 44 y/o LHM presented with a one month history of numbness and pain of the left middle finger and wrist. The numbness began in the left middle finger and gradually progressed over the course of a day to involve his wrist as well. Within a few days he developed pain in his wrist. He had been working as a cook and cut fish for prolonged periods of time. This activity exacerbated his symptoms. He denied any bowel/bladder difficulties, neck pain, or weakness. He had no history of neck injury.,SHX/FHX:, 1-2 ppd Cigarettes. Married. Off work for two weeks due to complaints.,EXAM: ,Vital signs unremarkable.,MS:, A & O to person, place, time. Fluent speech without dysarthria.,CN II-XII: ,Unremarkable,MOTOR:, 5/5 throughout, including intrinsic muscles of hands. No atrophy or abnormal muscle tone.,SENSORY:, Decreased PP in third digit of left hand only (palmar and dorsal sides).,STATION/GAIT/COORD:, Unremarkable.,REFLEXES: ,1+ throughout, plantar responses were downgoing bilaterally.,GEN EXAM: ,Unremarkable.,Tinel's manuever elicited pain and numbness on the left. Phalens sign present on the left.,CLINICAL IMPRESSION: ,Left Carpal Tunnel Syndrome,EMG/NCV: ,Unremarkable.,MRI C-spine, 12/1/92: Congenitally small spinal canal is present. Superimposed on this is mild spondylosis and disc bulge at C6-7, C5-6, C4-5, and C3-4. There is moderate central spinal stenosis at C3-4. Intervertebral foramina at these levels appear widely patent.,COURSE:, The MRI findings did not correlate with the clinical findings and history. The patient was placed on Elavil and was subsequently lost to follow-up.
---
DESCRIPTION: Left third digit numbness and wrist pain.

The situation involves a medical case with a diagnosis of left carpal tunnel syndrome, where the patient's symptoms include numbness and pain. There is an MRI finding of moderate central spinal stenosis, but it's noted that these findings do not correlate directly with the clinical symptoms. While it involves medical evaluation and potential treatment adjustments, it does not appear to pose an immediate life-threatening risk, nor is there any indication of severe neurological deficits or conditions like bowel/bladder dysfunction that would escalate the urgency. However, spinal and neurological issues can develop into more significant problems if not monitored, thus requiring attention but not an immediate high-stakes intervention.


Medical Specialty: Autopsy
Sample Name: Autopsy - 3

EXTERNAL EXAMINATION: , The autopsy is begun at 8:30 A.M. on May 24, 2004. The body is presented in a black body bag. The victim is wearing a white sleeveless turtleneck shirt and navy blue sweatpants. Jewelry included two smooth-textured silver hoop pierced earrings, 1-inch diameter, one in each ear, and one 1-inch wide silver expandable wristband on left wrist. A 1.5-inch wide tan belt with green stripes is cinched around the upper neck using the buckle. The opposite end of the belt is tied in a half-hitch knot, which was used to affix it to the crossbar in the closet where the body was found. ,The body is that of a normally developed white female measuring 67 inches and weighing 118 pounds, and appearing generally consistent with the stated age of twenty-six years. The body is cold and unembalmed. Lividity is fixed in the distal portions of the limbs. The eyes are open. The irises are brown and corneas are cloudy. Petechial hemorrhaging is present in the conjunctival surfaces of the eyes. The pupils measure 0.3 cm. The hair is dark blonde with lighter blonde highlights, wavy, layered and approximately 11 inches in length at the longest point. ,Removal of the belt revealed a ligature mark (known throughout this report as Ligature A) on the neck below the mandible. Ligature A is approximately 1.5 inches wide and encircles the neck in the form of a "V" on the anterior of the neck and an inverted "V" on the posterior of the neck, consistent with hanging. Minor abrasions are present in the area of Ligature A. Lack of hemorrhage surrounding Ligature A indicates this injury to be post-mortem. ,Upon removal of the victim's clothing, an odor of bleach was detected. Areas of the body were swabbed and submitted for detection of hypochlorite. Following removal of the shirt, a second ligature mark (known throughout this report as Ligature B) was observed on the victim's neck. The mark is dark red ligature and encircles the neck, crossing the anterior midline of the neck just below the laryngeal prominence. The width of the mark varies between 0.8 and 1cm and is horizontal in orientation. The skin of the anterior neck above and below the ligature mark shows petechial hemorrhaging. Ligature B is not consistent with the belt that caused Ligature A. The absence of abrasions associated with Ligature B, along with the variations in the width of the ligature mark, are consistent with a soft ligature, such as a length of fabric. No trace evidence was recovered from Ligature B that might assist in identification of the ligature used. ,The genitalia are that of an adult female and there is no evidence of injury. Pubic hair has been shaved in its entirety within six hours of death. Limbs are equal, symmetrically developed and show no evidence of injury. The fingernails are medium length and fingernail beds are blue. There are no residual scars, markings or tattoos.,INTERNAL EXAMINATION:  ,HEAD--CENTRAL NERVOUS SYSTEM: ,Subsequent autopsy shows a broken hyoid bone. Hemorrhaging from Ligature B penetrates the skin and subdermal tissues of the neck. The brain weighs 1,303 grams and within normal limits. ,SKELETAL SYSTEM:, The hyoid bone is fractured. ,RESPIRATORY SYSTEM--THROAT STRUCTURES: ,The oral cavity shows no lesions. Petechial hemorrhaging is present in the mucosa of the lips and the interior of the mouth. Otherwise, the mucosa is intact and there are no injuries to the lips, teeth or gums. ,There is no obstruction of the airway. The mucosa of the epiglottis, glottis, piriform sinuses, trachea and major bronchi are anatomic. No injuries are seen and there are no mucosal lesions. The hyoid bone, the thyroid, and the cricoid cartilages are fractured. ,The lungs weigh: right, 355 grams; left 362 grams. The lungs are unremarkable. ,CARDIOVASCULAR SYSTEM: ,The heart weighs 253 grams, and has a normal size and configuration. No evidence of atherosclerosis is present. ,GASTROINTESTINAL SYSTEM: ,The mucosa and wall of the esophagus are intact and gray-pink, without lesions or injuries. The gastric mucosa is intact and pink without injury. Approximately 125 ml of partially digested semisolid food is found in the stomach. The mucosa of the duodenum, jejunum, ileum, colon and rectum are intact. ,URINARY SYSTEM: ,The kidneys weigh: left, 115 grams; right, 113 grams. The kidneys are anatomic in size, shape and location and are without lesions. ,FEMALE GENITAL SYSTEM: ,The structures are within normal limits. Examination of the pelvic area indicates the victim had not given birth and was not pregnant at the time of death. There is evidence of recent sexual activity but no indications that the sexual contact was forcible. Vaginal fluid samples are removed for analysis. ,TOXICOLOGY: ,Sample of right pleural blood and bile are submitted for toxicologic analysis. Stomach contents are saved. ,SEROLOGY:, A sample of right pleural blood is submitted in the EDTA tube. Routine toxicologic studies were ordered.,LABORATORY DATA,CEREBROSPINAL FLUID CULTURE AND SENSITIVITY:,Gram stain: Unremarkable,Culture: No growth after 72 hours,CEREBROSPINAL FLUID BACTERIAL ANTIGENS:,Hemophilus influenza B: Negative,Streptococcus pneumoniae: Negative,N. Meningitidis: Negative,Neiserria meningitidis B/E. Coli K1: Negative ,Drug Screen Results:,URINE SCREEN {IMMUNOASSAY} WAS NEGATIVE. ,Ethanol: 0 gm/dl, Blood (Heart),Ethanol: 0 gm/dl, Vitreous ,EVIDENCE COLLECTED:,1. One (1) white turtleneck sleeveless shirt, size Small. ,2. One (1) pair navy blue sweatpants, size Small.,3. Two (2) silver hoop earrings. ,4. One (1) silver bracelet.,5. Samples of Blood (type O+), Bile, and Tissue (heart, lung, brain, kidney, liver, spleen). ,6. Fifteen (15) swabs from various body locations, to be tested for presence of hypochlorite.,7. Eleven (11) autopsy photographs.
---
DESCRIPTION: Autopsy - Asphyxia due to ligature strangulation.

This autopsy report involves a case of asphyxia due to ligature strangulation, which suggests the possibility of a suspicious or criminal death. The presence of multiple ligature marks, indications of recent sexual activity, and signs of bleach suggest efforts to alter or clean the crime scene. Such cases could have significant legal, forensic, and investigative implications, potentially impacting the judgment of criminal activity and justice delivery. Therefore, the situation is high-stakes as it may influence legal proceedings and require meticulous forensic examination.


Medical Specialty: General Medicine
Sample Name: Down's syndrome

SUBJECTIVE:,  This 46-year-old white male with Down’s syndrome presents with his mother for followup of hypothyroidism, as well as onychomycosis.  He has finished six weeks of Lamisil without any problems.  He is due to have an ALT check today.  At his appointment in April, I also found that he was hypothyroid with elevated TSH.  He was started on Levothroid 0.1 mg and has been taking that daily.  We will recheck a TSH today as well.  His mother notes that although he does not like to take the medications, he is taking it with encouragement.  His only other medications are some eyedrops for his cornea.,OBJECTIVE:,  Weight was 149 pounds, which is up 2 pounds.  Blood pressure was 120/80.  Pulse is 80 and regular.,Neck:  Supple without adenopathy.  No thyromegaly or nodules were palpable.,Cardiac:  Regular rate and rhythm without murmurs.,Skin:  Examination of the toenails showed really no change yet.  They are still quite thickened and yellowed.,ASSESSMENT:,1.  Down’s syndrome.,2.  Onychomycosis.,3.  Hypothyroidism.,PLAN:,1.  Recheck ALT and TSH today and call results.,2.  Lamisil 250 mg #30 one p.o. daily with one refill.  They will complete the next eight weeks of therapy as long as the ALT is normal.  I again reviewed the symptoms of liver dysfunction.,3.  Continue Levothroid 0.1 mg daily unless dosage need to be adjusted based on the TSH.
---
DESCRIPTION: A 46-year-old white male with Down’s syndrome presents for followup of hypothyroidism, as well as onychomycosis.

general medicine, down’s syndrome, hypothyroidism, onychomycosis, hypothyroid, tsh, down’s

The situation involves a follow-up appointment for managing chronic conditions in a patient with Down's syndrome. The stakes are moderate primarily due to the management of his hypothyroidism and potential liver function concerns from the medication Lamisil. Ensuring proper dosage of Levothroid and monitoring liver function is important to prevent complications, but these conditions are part of routine management in general medicine. The scenario does not involve immediate life-threatening decisions, hence it is not extremely high-stakes.


Medical Specialty: Orthopedic
Sample Name: Aspiration - Knee Joint

PREOPERATIVE DIAGNOSES: , Erythema of the right knee and leg, possible septic knee.,POSTOPERATIVE DIAGNOSES:,  Erythema of the right knee superficial and leg, right septic knee ruled out.,INDICATIONS: , Mr. ABC is a 52-year-old male who has had approximately eight days of erythema over his knee.  He has been to multiple institutions as an outpatient for this complaint.  He has had what appears to be prepatellar bursa aspirated with little to no success.  He has been treated with Kefzol and 1 g of Rocephin one point.  He also reports, in the emergency department today, an attempt was made to aspirate his actual knee joint which was unsuccessful.  Orthopedic Surgery was consulted at this time.  Considering the patient's physical exam, there is a portal that would prove to be outside of the erythema that would be useful for aspiration of the knee.  After discussion of risks and benefits, the patient elected to proceed with aspiration through the anterolateral portal of his knee joint.,PROCEDURE:  ,The patient's right anterolateral knee area was prepped with Betadine times two and a 20-gauge spinal needle was used to approach the knee joint approximately 3 cm anterior and 2 cm lateral to the superolateral pole of the patella.  The 20-gauge spinal needle was inserted and entered the knee joint.  Approximately, 4 cc of clear yellow fluid was aspirated.  The patient tolerated the procedure well.,DISPOSITION: , Based upon the appearance of this synovial fluid, we have a very low clinical suspicion of a septic joint.  We will send this fluid to the lab for cell count, crystal exam, as well as culture and Gram stain.  We will follow these results.  After discussion with the emergency department staff, it appears that they tend to try to treat his erythema which appears to be cellulitis with IV antibiotics.
---
DESCRIPTION: Erythema of the right knee and leg, possible septic knee. Aspiration through the anterolateral portal of knee joint.

orthopedic, knee and leg, anterolateral portal, emergency department, spinal needle, septic knee, knee joint, knee, emergency, department, gauge, spinal, needle, aspiration, anterolateral, portal, aspirated, fluid, septic, erythema, joint, aspiraion,

The situation involves diagnosing and treating potential septic arthritis, which is a serious condition if not promptly and correctly identified and treated. The aspiration procedure is key in ruling out a septic knee, a potentially high-stakes scenario that could lead to joint damage or systemic infection if mishandled. However, based on the aspiration results, there is low suspicion of infection, reducing the immediate stakes. Nonetheless, careful follow-up is necessary to ensure no complications arise and the erythema is managed appropriately.


Medical Specialty: Bariatrics
Sample Name: Laparoscopic Gastric Bypass Consult - 2

PAST MEDICAL HISTORY:, He has difficulty climbing stairs, difficulty with airline seats, tying shoes, used to public seating, and lifting objects off the floor.  He exercises three times a week at home and does cardio.  He has difficulty walking two blocks or five flights of stairs.  Difficulty with snoring.  He has muscle and joint pains including knee pain, back pain, foot and ankle pain, and swelling.  He has gastroesophageal reflux disease.,PAST SURGICAL HISTORY:, Includes reconstructive surgery on his right hand 13 years ago.  ,SOCIAL HISTORY:, He is currently single.  He has about ten drinks a year.  He had smoked significantly up until several months ago.  He now smokes less than three cigarettes a day.,FAMILY HISTORY:, Heart disease in both grandfathers, grandmother with stroke, and a grandmother with diabetes.  Denies obesity and hypertension in other family members.,CURRENT MEDICATIONS:, None.,ALLERGIES:,  He is allergic to Penicillin.,MISCELLANEOUS/EATING HISTORY:, He has been going to support groups for seven months with Lynn Holmberg in Greenwich and he is from Eastchester, New York and he feels that we are the appropriate program.  He had a poor experience with the Greenwich program.  Eating history, he is not an emotional eater.  Does not like sweets.  He likes big portions and carbohydrates.  He likes chicken and not steak.  He currently weighs 312 pounds.  Ideal body weight would be 170 pounds.  He is 142 pounds overweight.  If ,he lost 60% of his excess body weight that would be 84 pounds and he should weigh about 228.,REVIEW OF SYSTEMS: ,Negative for head, neck, heart, lungs, GI, GU, orthopedic, and skin.  Specifically denies chest pain, heart attack, coronary artery disease, congestive heart failure, arrhythmia, atrial fibrillation, pacemaker, high cholesterol, pulmonary embolism, high blood pressure, CVA, venous insufficiency, thrombophlebitis, asthma, shortness of breath, COPD, emphysema, sleep apnea, diabetes, leg and foot swelling, osteoarthritis, rheumatoid arthritis, hiatal hernia, peptic ulcer disease, gallstones, infected gallbladder, pancreatitis, fatty liver, hepatitis, hemorrhoids, rectal bleeding, polyps, incontinence of stool, urinary stress incontinence, or cancer.  Denies cellulitis, pseudotumor cerebri, meningitis, or encephalitis.,PHYSICAL EXAMINATION:, He is alert and oriented x 3.  Cranial nerves II-XII are intact.  Afebrile.  Vital Signs are stable.
---
DESCRIPTION: Consult for laparoscopic gastric bypass.

bariatrics, laparoscopic gastric bypass, weight loss programs, gastric bypass, atkin's diet, weight watcher's, body weight, laparoscopic gastric, weight loss, pounds, months, weight, laparoscopic, band, loss, diets, overweight, lost

The consultation is for a bariatric surgery, specifically a laparoscopic gastric bypass, which is generally considered when other weight loss efforts have not been successful. This is a significant surgical procedure with potential risks and long-term impacts on the patient's health and lifestyle. Additionally, the patient has a number of conditions related to obesity that can affect their quality of life. Hence, the decision to undergo surgery and the procedure itself can be seen as high-stakes due to its importance for the patient's health and its potential risks.


Medical Specialty: General Medicine
Sample Name: Chronic Abscesses - Discharge Summary

DISCHARGE DIAGNOSES,1.  Multiple extensive subcutaneous abscesses, right thigh.,2.  Massive open wound, right thigh, status post right excision of multiple subcutaneous abscesses, right thigh.,PROCEDURES PERFORMED,1.  On 03/05/08, by Dr. X, was massive debridement of soft tissue, right lateral thigh and hip.,2.  Soft tissue debridement on 03/16/08 of right thigh and hip by Dr. X.,3.  Split thickness skin graft to right thigh and right hip massive open wound on 04/01/08 by Dr. Y.,REASON FOR ADMISSION: , The patient is a 62-year-old male with a history of drug use.  He had a history of injection of heroin into his bilateral thighs.  Unfortunately, he developed chronic abscesses, open wounds on his bilateral thighs, much worse on his right than his left.  Decision was made to do a radical excision and then it is followed by reconstruction.,HOSPITAL COURSE:  ,The patient was admitted on 03/05/08 by Dr. X.  He was taken to the operating room.  He underwent a massive resection of multiple subcutaneous abscesses, heroin remnants, which left massive huge open wounds to his right thigh and hip.  This led to a prolonged hospital course.  The patient initially was treated with local wound care.  He was treated with broad spectrum antibiotics.  He ended up growing out different species of Clostridium.  Infectious Disease consult was obtained from Dr. Z.  He assisted in further antibiotic coverage throughout the rest of his hospitalization.  The patient also had significant hypoalbuminemia, decreased nutrition.  Given his large wounds, he did end up getting a feeding tube placement, and prior to grafting, he received significant feeding tube supplementation to help achieve adequate nutrition for healing.  The patient had this superior area what appeared to be further necrotic, infected soft tissue.  He went back to the OR on 03/16/08 and further resection done by Dr. X.  After this, his wound appeared to be free of infection.  He is treated with a wound VAC.  He slowly, but progressively had significant progress in his wound.  I went from a very poor-looking wound to a red granulated wound throughout its majority.  He was thought ready for skin grafting.  Note that the patient had serial ultrasounds given his high risk of DVT from this massive wound and need for decreased activity.  These were negative.  He was treated with SCDs to help decrease his risk.  On 04/01/08, the patient was taken to the operating room, was thought to have an adequate ________ grafting.  He underwent skin grafting to his right thigh and hip massive open wound.  Donor sites were truncated.  Postoperatively, the patient ended up with a vast majority of skin graft taking.  To unable to take, he was kept on IV antibiotics, strict bed rest, and limited range of motion of his hip.  He is continued on VAC dressing.  Graft progressively improved with this therapy.  Had another ultrasound, which was negative for DVT.  The patient was mobilized up out of his bed.  Infectious Disease recommendations were obtained.  Plan was to complete additional 10 days of antibiotics at discharge.  This will be oral antibiotics.  I would monitor his left side, which has significantly decreased inflammation and irritation or infection given the antibiotic coverage.  So, decision was not made to excise this, but instead monitor.  By 04/11/08, his graft looked good.  It was pink and filling in.  He looked stable for discharge.  The patient was discharged to home.,DISCHARGE INSTRUCTIONS: , Discharge to home.,CONDITION: , Stable.,Antibiotic Augmentin XR script was written.  He is okay to shower.  Donor site and graft site dressing instruction orders were given for Home Health and the patient.  His followup was arranged with Dr. X and myself.
---
DESCRIPTION: Multiple extensive subcutaneous abscesses, right thigh.  Massive open wound, right thigh, status post right excision of multiple subcutaneous abscesses, right thigh.

general medicine, multiple extensive subcutaneous abscesses, open wound, subcutaneous abscesses, multiple subcutaneous abscesses, skin grafting, thigh, wound, abscesses, wounds, subcutaneous, antibiotics,

The situation involves managing a complex medical case with multiple surgeries, infection management, and rehabilitation for a patient with a significant medical and substance use history. While the patient has been stabilized and discharged, there is ongoing risk, including potential for infection, wound healing, and compliance with at-home care instructions. The stakes are significant due to the complexity of care required post-discharge and potential complications.


Medical Specialty: Pediatrics - Neonatal
Sample Name: H&P - Infant with fever

CHIEF COMPLAINT:, Irritable baby with fever for approximately 24 hours.,HISTORY OF PRESENT ILLNESS:, This 6-week-old infant was doing well until about 48 hours prior to admission, developed irritability, fussiness, a little bit of vomiting, and then fever up to 103-degrees. The child was brought into the emergency room and a complete septic workup was done, and the child is being treated in a rule out sepsis protocol.,PAST MEDICAL HISTORY:, This child was born by term pregnancy, spontaneous vaginal delivery, to a mother who was a teenager. He is bottle fed and he has had his hepatitis B vaccine. He lives in a home where there are smokers. This is his first illness.,PAST SURGICAL HISTORY:, He has had no previous surgeries.,MEDICATION (S):, He takes no medications on a regular basis.,REVIEW OF SYSTEMS:, Positive for those things mentioned already in the past medical history and history of present illness.,FAMILY HISTORY:, The family history is noncontributory.,SOCIAL HISTORY:, This child lives with his mother and father, both are teenagers, unmarried, who are not well educated. Grandmother is a heavy smoker.,PHYSICAL EXAMINATION:,VITAL SIGNS: The vital signs are stable, the patient is febrile at 101-degrees.,HEAD, EYES, EARS, NOSE, AND THROAT/GENERAL: The anterior fontanelle is not bulging. The rest of the examination is within normal limits. The neck is supple, no nuchal rigidity noted, though this child is irritable and fussy, and whines and cries where ever you make touch him. He has an irritable disposition no matter what you do to him, and whines even while at rest.,HEART: The heart rate is rapid, but there was no murmur noted.,LUNGS: The lungs are clear.,ABDOMEN: The abdomen is without mass, distention, or visceromegaly.,GENITOURINARY/RECTAL: Examination within normal limits.,EXTREMITIES: The extremities are normal. No Kernig's or Brudzinski sign.,NEUROLOGIC: Cranial nerves II through XII are intact, no focal deficits. As I mentioned before, the child is extremely irritable, fussy, and has a great deal of general inconsolability.,SKIN: The child, in addition, has a skin pattern of cutis marmorata, which I think is a bit more exaggerated since the child is febrile and has some peripheral vasodilatation.,CLINICAL IMPRESSION (S):, Likely viral syndrome, viral meningitis, flu syndrome.,PLAN:, Continue the septic workup protocol, supportive care with IV fluids, and Tylenol as needed for fever, and continue the antibiotics until spinal fluid cultures and blood cultures are negative for 48 hours. In addition, I believe that the rapid heart rate is a sinus tachycardia, and is related to the child's illness, irritability, and his fever. In addition, there were no intracranial bruits noted.
---
DESCRIPTION: Irritable baby, 6-week-old, with fever for approximately 24 hours.

The situation involves a 6-week-old infant with a significant fever and irritability, symptoms that could potentially be indicative of a severe infection such as sepsis. Though initial assessments suggest a viral illness, the infant is undergoing a septic workup, which underscores the potential severity of the situation. In pediatrics, particularly with very young infants, symptoms like fever and irritability demand urgent and thorough evaluation due to the immature immune system and the rapid progression of illnesses at this age. The stakes are high because the outcome could significantly affect the infant's immediate health and well-being.


Medical Specialty: General Medicine
Sample Name: Gen Med Progress Note - 2

CHIEF COMPLAINT:,  Followup on hypertension and hypercholesterolemia.,SUBJECTIVE:,  This is a 78-year-old male who recently had his right knee replaced and also back surgery about a year and a half ago.  He has done well with that.  He does most of the things that he wants to do.  He travels at every chance he has, and he just got back from a cruise.  He denies any type of chest pain, heaviness, tightness, pressure, shortness of breath with stairs only, cough or palpitations.  He sees Dr. Ferguson.  He is known to have Crohn's and he takes care of that for him.  He sees Dr. Roszhart for his prostate check.  He is a nonsmoker and denies swelling in his ankles.,MEDICATIONS:, Refer to chart.,ALLERGIES:, Refer to chart.,PHYSICAL EXAMINATION:, ,Vitals:  Wt; 172 lbs, up 2 lbs,  B/P; 150/60, T; 96.4, P; 72 and regular.  ,General:  A 78-year-old male who does not appear to be in any acute distress.  Glasses.  Good dentition.,CV: Distant S1, S2 without murmur or gallop. No carotid bruits. P: 2+ all around.,Lungs: Diminished with increased AP diameter. ,Abdomen:  Soft, bowel sounds active x 4 quadrants. No tenderness, no distention, no masses or organomegaly noted.,Extremities:  Well-healed surgical scar on the right knee.  No edema.  Hand grasps are strong and equal.,Back:  Surgical scar on the lower back.,Neuro: Intact.  A&O. Moves all four with no focal motor or sensory deficits.,IMPRESSION:,1.  Hypertension.,2.  Hypercholesterolemia.,3.  Osteoarthritis.,4.  Fatigue.,PLAN:,  We will check a BMP, lipid, liver profile, CPK, and CBC.  Refill his medications x 3 months.  I gave him a copy of Partners in Prevention.  Increase his Altace to 5 mg day for better blood pressure control.  Diet, exercise, and weight loss, and we will see him back in three months and p.r.n.
---
DESCRIPTION: Sample progress note - Gen Med.

Sample progress note - Gen Med.

general medicine, progress note, fatigue, osteoarthritis, back surgery, chest pain, cough, heaviness, hypercholesterolemia, hypertension, palpitations, pressure, shortness of breath, tightness, surgical scar, progress,

The situation described involves a routine follow-up for a 78-year-old male with a focus on managing conditions like hypertension and hypercholesterolemia. While it involves the management of chronic conditions, the absence of acute distress, serious symptoms, or life-threatening conditions makes it a standard follow-up appointment rather than a high-stakes situation. The patient's overall health appears stable, and the plan includes standard lab tests and medication adjustments typical for managing these conditions.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Lexiscan Nuclear Scan

EXAM:,  Lexiscan Nuclear Myocardial Perfusion Scan.,INDICATION:,  Chest pain.,TYPE OF TEST:  ,Lexiscan, unable to walk on a treadmill.,INTERPRETATION: , Resting heart rate of 96, blood pressure of 141/76.  EKG, normal sinus rhythm, nonspecific ST-T changes, left bundle branch block.  Post Lexiscan 0.4 mg injected intravenously by standard protocol.  Peak heart rate was 105, blood pressure of 135/72.  EKG remains the same.  No symptoms are noted.,SUMMARY:,1.  Nondiagnostic Lexiscan.,2.  Nuclear interpretation as below.,NUCLEAR MYOCARDIAL PERFUSION SCAN WITH STANDARD PROTOCOL:,  Resting and stress images were obtained with 10.4, 32.5 mCi of tetrofosmin injected intravenously by standard protocol.  Myocardial perfusion scan demonstrates homogeneous and uniform distribution of the tracer uptake.  There is no evidence of reversible or fixed defect.  Gated SPECT revealed mild global hypokinesis, more pronounced in the septal wall possibly secondary to prior surgery.  Ejection fraction calculated at 41%.  End-diastolic volume of 115, end-systolic volume of 68.,IMPRESSION:,1.  Normal nuclear myocardial perfusion scan.,2.  Ejection fraction 41% by gated SPECT.
---
DESCRIPTION: Lexiscan Nuclear Myocardial Perfusion Scan.  Chest pain.  Patient unable to walk on a treadmill.  Nondiagnostic Lexiscan.  Normal nuclear myocardial perfusion scan.

cardiovascular / pulmonary, lexiscan nuclear myocardial perfusion scan, treadmill, bundle branch block, mci, tetrofosmin, nuclear myocardial perfusion scan, blood pressure, gated spect, ejection fraction, myocardial perfusion, ejection, fraction, myocardial, lexiscan, nuclear,

The Lexiscan Nuclear Myocardial Perfusion Scan is a diagnostic test used to evaluate heart function and blood flow. The results indicate a normal myocardial perfusion scan and an ejection fraction of 41%, which is somewhat low. While the test is generally routine, the presence of chest pain and potential heart issues adds some level of seriousness due to possible underlying conditions, such as heart disease. However, this test was nondiagnostic and without immediate symptoms noted, suggesting that immediate high-stakes concerns may not currently be present. Overall, the situation is moderately serious due to the need to manage and monitor the heart condition.


Medical Specialty: Surgery
Sample Name: Gastroscopy - 3

PROCEDURE: , Gastroscopy.,PREOPERATIVE DIAGNOSIS: , Gastroesophageal reflux disease.,POSTOPERATIVE DIAGNOSIS:,  Barrett esophagus.,MEDICATIONS: , MAC.,PROCEDURE: , The Olympus gastroscope was introduced into the oropharynx and passed carefully through the esophagus, stomach, and duodenum to the transverse duodenum.  The preparation was excellent and all surfaces were well seen.  The hypopharynx appeared normal.  The esophagus had a normal contour and normal mucosa throughout its distance, but at the distal end, there was a moderate-sized hiatal hernia noted.  The GE junction was seen at 40 cm and the hiatus was noted at 44 cm from the incisors.  Above the GE junction, there were three fingers of columnar epithelium extending cephalad, to a distance of about 2 cm.  This appears to be consistent with Barrett esophagus.  Multiple biopsies were taken from numerous areas in this region.  There was no active ulceration or inflammation and no stricture.  The hiatal hernia sac had normal mucosa except for one small erosion at the hiatus.  The gastric body had normal mucosa throughout.  Numerous small fundic gland polyps were noted, measuring 3 to 5 mm in size with an entirely benign appearance.  Biopsies were taken from the antrum to rule out Helicobacter pylori.  A retroflex view of the cardia and fundus confirmed the small hiatal hernia and demonstrated no additional lesions.  The scope was passed through the pylorus, which was patent and normal.  The mucosa throughout the duodenum in the first, second, and third portions was entirely normal.  The scope was withdrawn and the patient was sent to the recovery room.  He tolerated the procedure well.,FINAL DIAGNOSES:,1.  A short-segment Barrett esophagus.,2.  Hiatal hernia.,3.  Incidental fundic gland polyps in the gastric body.,4.  Otherwise, normal upper endoscopy to the transverse duodenum.,RECOMMENDATIONS:,1.  Follow up biopsy report.,2.  Continue PPI therapy.,3.  Follow up with Dr. X as needed.,4.  Surveillance endoscopy for Barrett in 3 years (if pathology confirms this diagnosis).
---
DESCRIPTION: Gastroscopy.  A short-segment Barrett esophagus, hiatal hernia, and incidental fundic gland polyps in the gastric body; otherwise, normal upper endoscopy to the transverse duodenum.

surgery, olympus, gastroscope, barrett, gastroesophageal reflux disease, transverse duodenum, barrett esophagus, hiatal hernia, gastroscopy, endoscopy, hiatal, duodenum, esophagus, hernia,

While the procedure and findings concern conditions that may have significant implications for the patient's long-term health, such as Barrett esophagus and hiatal hernia, the stakes during or immediately following the procedure are moderate due to the non-critical nature of the findings. The patient is not in immediate danger, as evidenced by the absence of ulcers, strictures, or malignancies, and the recommendation for follow-up is in several years, indicating a manageable situation. Therefore, while there's potential for future complications, the current scenario doesn't involve urgent risk.


Medical Specialty: ENT - Otolaryngology
Sample Name: Vertigo Consult - 1

Patient had a normal MRI and normal neurological examination on August 24, 2010.,Assessment for peripheral vestibular function follows:,Most clinical tests were completed with difficulty and poor cooperation.,OTOSCOPY:, showed bilateral intact tympanic membranes with central  Weber test and bilateral positive Rinne.,ROMBERG TEST:, maintained postural stability with difficulty.,Frenzel glasses examination: no spontaneous, end gaze nystagmus.,DIX-HALLPIKE:, showed no positional nystagmus excluding benign paroxysmal positional vertigo.,HEAD SHAKING AND VESTIBULOCULAR REFLEX [HALMAGYI TEST]:, were done with difficulty a short corrective saccades may give the possibility if having a decompensated vestibular hypofunction. ,IMPRESSION:, Decompensation vestibular hypofunction documented by further electronystagmography and caloric testing. ,PLAN:,  Booked for electronystagmography and advised to continue with her vestibular rehabilitation exercises, in addition to supportive medical treatment in the form of betahistine 24 mg twice a day.
---
DESCRIPTION: The patient is having recurrent attacks of imbalance rather than true vertigo following the history of head trauma and loss of consciousness.  Symptoms are not accompanied by tinnitus or deafness.

ent - otolaryngology, tinnitus, deafness, imbalance, nystagmus, hypofunction, electronystagmography, vertigo, vestibular,

The situation involves a patient with potential vestibular dysfunction following head trauma, but there is no immediate life-threatening condition, such as a stroke or cardiac arrest, indicated in the examination results. Despite difficulties in testing, the MRI and neurological exam were normal, meaning acute neurological damage is unlikely. The high-stakes elements are mitigated by the plan for ongoing tests and treatment. While conditions affecting balance can significantly impact quality of life, they do not typically present imminent danger. Thus, this situation is lower in stakes compared to emergencies but still important for patient care.


Medical Specialty: Surgery
Sample Name: ORIF - Left Tibia

PREOPERATIVE DIAGNOSIS: , Left tibial tubercle avulsion fracture.,POSTOPERATIVE DIAGNOSIS:,  Comminuted left tibial tubercle avulsion fracture with intraarticular extension.,PROCEDURE:,  Open reduction and internal fixation of left tibia.,ANESTHESIA: , General.  The patient received 10 ml of 0.5% Marcaine local anesthetic.,TOURNIQUET TIME: , 80 minutes.,ESTIMATED BLOOD LOSS:,  Minimal.,DRAINS: , One JP drain was placed.,COMPLICATIONS: , No intraoperative complications or specimens.  Hardware consisted of two 4-5 K-wires, One 6.5, 60 mm partially threaded cancellous screw and one 45, 60 mm partially threaded cortical screw and 2 washers.,HISTORY AND PHYSICAL:,  The patient is a 14-year-old male who reported having knee pain for 1 month.  Apparently while he was playing basketball on 12/22/2007 when he had gone up for a jump, he felt a pop in his knee.  The patient was seen at an outside facility where he was splinted and subsequently referred to Children's for definitive care.  Radiographs confirmed comminuted tibial tubercle avulsion fracture with patella alta.  Surgery is recommended to the grandmother and subsequently to the father by phone.  Surgery would consist of open reduction and internal fixation with subsequent need for later hardware removal.  Risks of surgery include the risks of  anesthesia, infection, bleeding, changes on sensation in most of the extremity, hardware failure, need for later hardware removal, failure to restore extensor mechanism tension, and need for postoperative rehab.  All questions were answered, and father and grandmother agreed to the above plan.,PROCEDURE: , The patient was taken to the operating and placed supine on the operating table.  General anesthesia was then administered.  The patient was given Ancef preoperatively.  A nonsterile tourniquet was placed on the upper aspect of the patient's left thigh.  The patient's extremity was then prepped and draped in the standard surgical fashion.  Midline incision was marked on the skin extending from the tibial tubercle proximally and extremities wrapped in Esmarch.  Finally, the patient had tourniquet that turned in 75 mmHg.  Esmarch was then removed.  The incision was then made.  The patient had significant  tearing of the posterior retinaculum medially with proximal migration of the tibial tubercle which was located in the joint there was a significant comminution and intraarticular involvement.  We were able to see the underside of the anterior horn of both medial and lateral meniscus.  The intraarticular cartilage was restored using two 45 K-wires.  Final position was checked via fluoroscopy and the corners were buried in the cartilage.  There was a large free floating metaphyseal piece that included parts of proximal tibial physis.  This was placed back in an anatomic location and fixed using a 45 cortical screw with a washer.  The avulsed fragment with the patellar tendon was then fixed distally to this area using a 6.5, 60 mm cancellous screw with a washer.  The cortical screw did not provide good compression and fixation at this distal fragment.  Retinaculum was repaired using 0 Vicryl suture as best as possible.  The hematoma was evacuated at the beginning of the case as well as the end.  The knee was copiously irrigated with normal saline.  The subcutaneous tissue was re-approximated using 2-0 Vicryl and the skin with 4-0 Monocryl.  The wound was cleaned, dried, and dressed with Steri-Strips, Xeroform, and 4 x4s.  Tourniquet was released at 80 minutes.  JP drain was placed on the medium gutter.  The extremity was then wrapped in Ace wrap from the proximal thigh down to the toes.  The patient was then placed in a knee mobilizer.  The patient tolerated the procedure well.  Subsequently extubated and taken to the recovery in stable condition.,POSTOP PLAN:  ,The patient hospitalized overnight to decrease swelling and as well as manage his pain.  He may weightbear as tolerated using knee mobilizer.  Postoperative findings relayed to the grandmother.  The patient will need subsequent hardware removal.  The patient also was given local anesthetic at the end of the case.
---
DESCRIPTION: Open reduction and internal fixation of left tibia.

surgery, intraarticular extension, tibial tubercle avulsion fracture, tubercle avulsion fracture, jp drain, cortical screw, hardware removal, tibial tubercle, tourniquet, orif, tubercle, tibial,

The situation involves a surgical procedure, specifically an open reduction and internal fixation of a left tibia fracture with intraarticular extension in a 14-year-old patient. Surgical procedures inherently come with risks such as complications from anesthesia, infection, and the need for future surgeries (such as hardware removal in this case). Although there were no complications recorded during the operation, the stakes are still high due to the young age of the patient, the potential impact on mobility and growth, and the requirement for post-operative care and potential further interventions. The surgery's success has significant implications for the patient's immediate recovery, long-term knee function, and quality of life. Given these factors, while the surgery was completed successfully without complications, it remains a high-stakes situation because of the involved risks, the necessity for future procedures, and the impact on a minor patient's well-being.


Medical Specialty: Surgery
Sample Name: EGD with Biopsy - 2

TYPE OF PROCEDURE: , Esophagogastroduodenoscopy with biopsy.,PREOPERATIVE DIAGNOSIS:,  Abdominal pain.,POSTOPERATIVE DIAGNOSIS:,  Normal endoscopy.,PREMEDICATION: , Fentanyl 125 mcg IV, Versed 8 mg IV.,INDICATIONS:  ,This healthy 28-year-old woman has had biliary colic-type symptoms for the past 3-1/2 weeks, characterized by severe pain, and brought on by eating greasy foods.  She has had similar episodes couple of years ago and was told, at one point, that she had gallstones, but after her pregnancy, a repeat ultrasound was done, and apparently was normal, and nothing was done at that time.  She was evaluated in the emergency department recently, when she developed this recurrent pain, and laboratory studies were unrevealing.  Ultrasound was normal and a HIDA scan was done, which showed a low normal ejection fraction of 40%, and moderate reproduction of her pain.  Endoscopy was requested to make sure there is not upper GI source of her pain before considering cholecystectomy.,PROCEDURE: , The patient was premedicated and the Olympus GIF 160 video endoscope advanced to the distal duodenum.  Gastric biopsies were taken to rule out Helicobacter and the procedure was completed without complication.,IMPRESSION:  ,Normal endoscopy.,PLAN: , Refer to a general surgeon for consideration of cholecystectomy.
---
DESCRIPTION: Esophagogastroduodenoscopy with biopsy.  Patient has had biliary colic-type symptoms for the past 3-1/2 weeks, characterized by severe pain, and brought on by eating greasy foods.

surgery, hida scan, endoscopy, gallstones, olympus, esophagogastroduodenoscopy with biopsy, biliary colic, colic type, greasy foods, normal endoscopy, esophagogastroduodenoscopy, biliary, colic, greasy, foods, cholecystectomy, biopsy,

The procedure described is an esophagogastroduodenoscopy (EGD) with biopsy for a patient experiencing biliary colic-type symptoms. While the procedure itself is an important diagnostic tool, it's a routine endoscopic examination with a low risk of complications, performed to investigate a possible upper GI source of pain. The post-procedure finding was a normal endoscopy, and the next step is a referral for potential cholecystectomy. Although the situation involves medical decision-making, it does not involve immediate life-threatening conditions or complex surgery at this stage, making it relatively low-stakes.


Medical Specialty: General Medicine
Sample Name: Discharge Summary - 8

DISCHARGE DIAGNOSES:,1.  Gram-negative rod bacteremia, final identification and susceptibilities still pending.,2.  History of congenital genitourinary abnormalities with multiple surgeries before the 5th grade.,3.  History of urinary tract infections of pyelonephritis.,OPERATIONS PERFORMED: , Chest x-ray July 24, 2007, that was normal.  Transesophageal echocardiogram July 27, 2007, that was normal.  No evidence of vegetations.  CT scan of the abdomen and pelvis July 27, 2007, that revealed multiple small cysts in the liver, the largest measuring 9 mm.  There were 2-3 additional tiny cysts in the right lobe.  The remainder of the CT scan was normal.,HISTORY OF PRESENT ILLNESS: , Briefly, the patient is a 26-year-old white female with a history of fevers.  For further details of the admission, please see the previously dictated history and physical.  ,HOSPITAL COURSE:,  Gram-negative rod bacteremia.  The patient was admitted to the hospital with suspicion of endocarditis given the fact that she had fever, septicemia, and Osler nodes on her fingers.  The patient had a transthoracic echocardiogram as an outpatient, which was equivocal, but a transesophageal echocardiogram here in the hospital was normal with no evidence of vegetations.  The microbiology laboratory stated that the Gram-negative rod appeared to be anaerobic, thus raising the possibility of organisms like bacteroides.  The patient does have a history of congenital genitourinary abnormalities which were surgically corrected before the fifth grade.  We did a CT scan of the abdomen and pelvis, which only showed some benign appearing cysts in the liver.  There was nothing remarkable as far as her kidneys, ureters, or bladder were concerned.  I spoke with Dr. XYZ of infectious diseases, and Dr. XYZ asked me to talk to the patient about any contact with animals, given the fact that we have had a recent outbreak of tularemia here in Utah.  Much to my surprise, the patient told me that she had multiple pet rats at home, which she was constantly in contact with.  I ordered tularemia and leptospirosis serologies on the advice of Dr. XYZ, and as of the day after discharge, the results of the microbiology still are not back yet.  The patient, however, appeared to be responding well to levofloxacin.  I gave her a 2-week course of 750 mg a day of levofloxacin, and I have instructed her to follow up with Dr. XYZ in the meantime.  Hopefully by then we will have a final identification and susceptibility on the organism and the tularemia and leptospirosis serologies will return.  A thought of ours was to add doxycycline, but again the patient clinically appeared to be responding to the levofloxacin.  In addition, I told the patient that it would be my recommendation to get rid of the rats.  I told her that if indeed the rats were carriers of infection and she received a zoonotic infection from exposure to the rats, that she could be in ongoing continuing danger and her children could also potentially be exposed to a potentially lethal infection.  I told her very clearly that she should, indeed, get rid of the animals.  The patient seemed reluctant to do so at first, but I believe with some coercion from her family, that she finally came to the realization that this was a recommendation worth following.,  ,DISPOSITION,DISCHARGE INSTRUCTIONS: , Activity is as tolerated.  Diet is as tolerated.,MEDICATIONS: , Levaquin 750 mg daily x14 days.,Followup is with Dr. XYZ of infectious diseases.  I gave the patient the phone number to call on Monday for an appointment.  Additional followup is also with Dr. XYZ, her primary care physician.  Please note that 40 minutes was spent in the discharge.
---
DESCRIPTION: A white female with a history of fevers.

general medicine, abdomen and pelvis, gram negative rod, congenital genitourinary, genitourinary abnormalities, transesophageal echocardiogram, infectious diseases, leptospirosis serologies, gram negative, ct scan, identification, infections, levofloxacin, additional, discharge

The situation involves a patient with a serious bacterial infection (Gram-negative rod bacteremia) that is potentially linked to her pets, posing a risk of zoonotic transmission. While currently there is no immediate life-threatening condition since the patient is responding well to treatment, the incomplete identification and susceptibilities of the bacteria mean there is ongoing uncertainty. Moreover, the potential public health risk due to a zoonotic disease like tularemia increases the stakes, as it requires careful monitoring and follow-up. However, since the patient is under medical supervision and responding positively to treatment, it's not the most critical medical emergency.


Medical Specialty: Radiology
Sample Name: Five views of the right knee.

EXAM: , Five views of the right knee.,HISTORY: , Pain.  The patient is status-post surgery, he could not straighten his leg, pain in the back of the knee.,TECHNIQUE:,  Five views of the right knee were evaluated.  There are no priors for comparison.,FINDINGS: , Five views of the right knee were evaluated and they reveal there is no evidence of any displaced fractures, dislocations, or subluxations.  There are multiple areas of growth arrest lines seen in the distal aspect of the femur and proximal aspect of the tibia.  There is also appearance of a high-riding patella suggestive of patella alta.,IMPRESSION:,1.  No evidence of any displaced fractures, dislocations, or subluxations.,2.  Growth arrest lines seen in the distal femur and proximal tibia.,3.  Questionable appearance of a slightly high-riding patella, possibly suggesting patella alta.
---
DESCRIPTION: Sample Radiology report of knee (growth arrest lines).

radiology, fractures dislocations or subluxations, femur and proximal, growth arrest lines, patella alta, fractures, dislocations, subluxations, distal, femur, patella

This situation involves the evaluation of a post-surgical knee through radiology to assess the presence of fractures, dislocations, or other abnormalities. While the findings indicate some potential issues, such as growth arrest lines and the suggestion of patella alta, there are no immediate or severe abnormalities found, like displaced fractures or significant dislocations. Therefore, the situation is not highly critical but still requires attention due to the patient's pain and post-surgery status. It is important for the medical practitioner to interpret these findings in context and to decide on further management or interventions.


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

Medical Specialty: Dermatology
Sample Name: Mohs Micrographic Surgery - 2

PREOP DIAGNOSIS: , Basal Cell CA.,POSTOP DIAGNOSIS:,  Basal Cell CA.,LOCATION:  ,Medial right inferior helix.,PREOP SIZE:,  1.4 x 1 cm,POSTOP SIZE: , 2.7 x 2 cm,INDICATION: , Poorly defined borders.,COMPLICATIONS: , None.,HEMOSTASIS: , Electrodessication.,PLANNED RECONSTRUCTION: , Wedge resection advancement flap.,DESCRIPTION OF PROCEDURE: , Prior to each surgical stage, the surgical site was tested for anesthesia and reanesthetized as needed, after which it was prepped and draped in a sterile fashion.,The clinically-apparent tumor was carefully defined and debulked prior to the first stage, determining the extent of the surgical excision.  With each stage, a thin layer of tumor-laden tissue was excised with a narrow margin of normal appearing skin, using the Mohs fresh tissue technique.  A map was prepared to correspond to the area of skin from which it was excised.  The tissue was prepared for the cryostat and sectioned.  Each section was coded, cut and stained for microscopic examination.  The entire base and margins of the excised piece of tissue were examined by the surgeon.  Areas noted to be positive on the previous stage (if applicable) were removed with the Mohs technique and processed for analysis.,No tumor was identified after the final stage of microscopically controlled surgery.  The patient tolerated the procedure well without any complication.  After discussion with the patient regarding the various options, the best closure option for each defect was selected for optimal functional and cosmetic results.
---
DESCRIPTION: Mohs Micrographic Surgery for basal cell CA at medial right inferior helix.

dermatology, medial right inferior helix, wedge resection advancement flap, tumor-laden tissue, mohs fresh tissue technique, mohs technique, mohs micrographic surgery, basal cell ca, micrographic surgery, basal cell, micrographic, helix, basal, cell, ca, mohs, tissue, stage,

This situation involves a routine dermatological procedure. Mohs micrographic surgery is a common and established technique for excising certain types of skin cancer like basal cell carcinoma. While it is a surgical procedure, it is typically performed on an outpatient basis with local anesthesia and has a high success rate with minimal complications. The details provided indicate that the procedure was completed successfully, and there were no complications. Therefore, given it's a controlled medical environment with a well-documented procedure, it represents a relatively low-stakes situation compared to more critical medical interventions.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Hysterectomy - Discharge Summary - 2

ADMISSION DIAGNOSIS: , Microinvasive carcinoma of the cervix.,DISCHARGE DIAGNOSIS: , Microinvasive carcinoma of the cervix.,PROCEDURE PERFORMED: , Total vaginal hysterectomy.,HISTORY OF PRESENT ILLNESS: , The patient is a 36-year-old, white female, gravida 7, para 5, last period mid March, status post tubal ligation.  She had an abnormal Pap smear in the 80s, which she failed to followup on until this year.  Biopsy showed a microinvasive carcinoma of the cervix and a cone biopsy was performed on 02/12/2007 also showing microinvasive carcinoma with a 1 mm invasion.  She has elected definitive therapy with a total vaginal hysterectomy.  She is aware of the future need of Pap smears.,PAST MEDICAL HISTORY: , Past history is significant for seven pregnancies, five term deliveries, and significant past history of tobacco use.,PHYSICAL EXAMINATION: , Physical exam is within normal limits with a taut normal size uterus and a small cervix, status post cone biopsy.,LABORATORY DATA AND DIAGNOSTIC STUDIES: , Chest x-ray was clear.  Discharge hemoglobin 10.8.,HOSPITAL COURSE: , She was taken to the operating room on 04/02/2007 where a total vaginal hysterectomy was performed under general anesthesia.  There was an incidental cystotomy at the time of the creation of the bladder flap.  This was repaired intraoperatively without difficulty.  Postoperative, she did very well.  Bowel and bladder function returned quickly.  She is ambulating well and tolerating a regular diet.,Routine postoperative instructions given and understood.  Followup will be in ten days for a cystogram and catheter removal with followup in the office at that time. ,DISCHARGE MEDICATIONS:,  Vicodin, Motrin, and Macrodantin at bedtime for urinary tract infection suppression.  ,DISCHARGE CONDITION: , Good.,Final pathology report was free of residual disease.
---
DESCRIPTION: Total vaginal hysterectomy.  Microinvasive carcinoma of the cervix.

obstetrics / gynecology, pap smear, total vaginal hysterectomy, hysterectomy, microinvasive, carcinoma, cervix,

The situation involves a medical discharge summary of a patient who underwent a total vaginal hysterectomy due to microinvasive carcinoma of the cervix. The diagnosis and surgical procedure indicate a significant health concern, as it relates to cancer treatment. While the procedure was successful and the patient's discharge condition is good, the situation retains elements of high-stakes because it pertains to a serious medical condition (cancer) and the surgical intervention required to address it. However, given the successful treatment and discharge, the immediacy of the high-stakes nature is somewhat mitigated.


Medical Specialty: Radiology
Sample Name: Diagnostic Mammogram

EXAM: , Bilateral diagnostic mammogram and right breast ultrasound.,History of palpable abnormality at 10 o'clock in the right breast.  Family history of a sister with breast cancer at age 43.,TECHNIQUE: , CC and MLO views of both breasts were obtained.  Spot compression views of the palpable area were also obtained.  Right breast ultrasound was performed.  Comparison is made with mm/dd/yy.,FINDINGS: , The breast parenchymal pattern is stable with heterogeneous scattered areas of fibroglandular tissue.  No new mass or architectural distortion is evident.  Asymmetric density in the upper outer posterior left breast and a nodule in the upper outer right breast are unchanged.  There is no suspicious cluster of microcalcifications.,Directed ultrasonography of the upper outer quadrant of the right breast revealed no cystic or hypoechoic solid mass.,IMPRESSION:,1.  Stable mammographic appearance from mm/dd/yy.,2.  No sonographic evidence of a mass at 10 o'clock in the right breast to correspond to the palpable abnormality.  The need for further assessment of a palpable abnormality should be determined clinically.,BIRADS Classification 2 - Benign
---
DESCRIPTION: Diagnostic Mammogram and ultrasound of the breast.

radiology, diagnostic mammogram, diagnostic, mammogram, ultrasound, palpable

This situation involves evaluating a diagnostic mammogram and ultrasound results for a patient with a palpable abnormality and a family history of breast cancer. While the findings are benign according to BIRADS Classification 2, the stakes remain significant as the patient has a family history of breast cancer, necessitating careful observation and potential further assessment. The outcome directly impacts health management and the patient's peace of mind, making it moderately high-stakes.


Medical Specialty: Orthopedic
Sample Name: Hemiarthroplasty - Austin-Moore Bipolar

PREOPERATIVE DIAGNOSIS: , Subcapital left hip fracture.,POSTOPERATIVE DIAGNOSIS: , Subcapital left hip fracture.,PROCEDURE PERFORMED: , Austin-Moore bipolar hemiarthroplasty, left hip.,ANESTHESIA:  ,Spinal.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:  ,Less than 100 cc.,HISTORY:  ,The patient is an 86-year-old female who was seen and evaluated in ABCD General Hospital Emergency Department on 08/30/03 after sustaining a fall at her friend's house.  The patient states that she was knocked over by her friend's dog.  She sustained a subcapital left hip fracture.  Prior to admission, she lived alone in Terrano, was ambulating with a walker.  All risks, benefits, and potential complications of the procedure were then discussed with the patient and informed consent was obtained.,HARDWARE SPECIFICATIONS: , A 28 mm medium head was used, a small cemented femoral stem was used, and a 28 x 46 cup was used.,PROCEDURE:  ,All risks, benefits, and potential complications of the procedure were discussed with the patient, informed consent was obtained.  She was then transferred from the preoperative care unit to operating suite #1.  Department of Anesthesia administered spinal anesthetic without complications.,After this, the patient was transferred to the operating table and positioned.  All bony prominences were well padded.  She was positioned on a beanbag in the right lateral decubitus position with the left hip facing upwards.  The left lower extremity was then sterilely prepped and draped in the normal fashion.  A skin maker was then used to mark all bony prominences.  Skin incision was then carried out extending from the greater trochanter in a curvilinear fashion posteriorly across the buttocks.  A #10 blade Bard-Parker scalpel was used to incise the skin through to the subcutaneous tissues.  A second #10 blade was then used to incise through the subcutaneous tissue down to the fascia lata.  This was then incised utilizing Metzenbaum scissors.  This was taken down to the bursa, which was removed utilizing a rongeur.  Utilizing a periosteal elevator as well as the sponge, the fat was then freed from the short external rotators of the left hip after these were placed and stretched.  The sciatic nerve was then visualized and retracted utilizing a Richardson retractor.  Bovie was used to remove the short external rotators from the greater trochanter, which revealed the joint capsule.  The capsule was cleared and incised utilizing a T-shape incision.  A fracture hematoma was noted upon entering the joint capsule as well as subcapital hip fracture.  A cork screw was then used to remove the fractured femoral head, which was given to the scrub tech which was sized on the back table.  All bony remnants were then removed from the acetabulum and surrounding soft tissue with a rongeur.  Acetabulum was then inspected and found to be clear.  Attention was then turned to the proximal femur where a cutting tunnel was used to mark the femur for the femoral neck cut.  An oscillating saw was then used to make the femoral cut.  Box osteotome was then used to remove the bone from proximal femur.  A Charnley awl was then used to open the femoral canal, paying close attention to keep the awl in the lateral position.  Next, attention was turned to broaching.  Initially, a small broach was placed, first making efforts to lateralize the broach then the femoral canal.  It was felt that the patient has less benefit from a cemented prosthesis and a small size was appropriate.  Next, the trial components were inserted consisting of the above-mentioned component sizes.  The hip was taken through range of motion and tested to adduction, internal and external rotations as well as with a shuck and a posterior directed force on a flexed tip.  It was noted that these size were stable through the range of motion.  Next, the trial components were removed and the femoral canal was copiously irrigated and suctioned dried utilizing Super sucker and __________ then inserted pressuring the femoral canal.  The femoral component was then inserted and then held under pressure.  Extruding cement was removed from the proximal femur.  After the cement had fully hardened and dried, the head and cup were applied.  The hip was subsequently reduced and taken again through range of motion, which was felt to be stable.,Next, the capsule was closed utilizing #1 Ethibond in figure-of-eight fashion.  Next, the fascia lata was repaired utilizing a figure-of-eight Ethibond sutures.  The most proximal region at the musculotendinous junction was repaired utilizing a running #1 Vicryl suture.  The wound was then copiously irrigated again to suction dry.  Next, the subcutaneous tissues were reapproximated using #2-0 Vicryl simple interrupted sutures.  The skin was then reapproximated utilizing skin clips.  Sterile dressing was applied consisting of Adaptic, 4x4s, ABDs as well as foam tape.  The patient was then transferred from the operating table to the gurney.  Leg lengths were checked, which were noted to be equal and abduction pillow was placed.  The patient was then transferred to the Postoperative Care Unit in stable condition.
---
DESCRIPTION: Austin-Moore bipolar hemiarthroplasty, left hip.  Subcapital left hip fracture.

orthopedic, austin-moore bipolar hemiarthroplasty, subcapital left hip fracture, hip fracture, austin moore bipolar hemiarthroplasty, subcutaneous tissues, hip, hemiarthroplasty, austin, cemented, femur, subcapital, fracture, femoral,

This case involves an orthopedic surgical procedure, specifically a hemiarthroplasty for a subcapital hip fracture in an elderly patient. While the surgery itself is routine for orthopedic surgeons, it is still a significant medical procedure with potential risks, particularly in an 86-year-old patient. Age and the nature of the surgery slightly elevate the stakes compared to younger patients undergoing the same procedure. However, the described operation was completed without complications, suggesting effective management. Prior to the operation, informed consent was obtained after discussing the risks and benefits, which is standard practice. Overall, while this is a serious and important procedure, it is not extraordinarily high-stakes given the patient's post-operative stability and lack of complications.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: PAF - 6-Month Followup

REASON FOR VISIT:,  Six-month follow-up visit for paroxysmal atrial fibrillation (PAF).,She reports that she is getting occasional chest pains with activity.  Sometimes she feels that at night when she is lying in bed and it concerns her.,She is frustrated by her inability to lose weight even though she is hyperthyroid.,MEDICATIONS: , Tapazole 10 mg b.i.d., atenolol/chlorthalidone 50/25 mg b.i.d., Micro-K 10 mEq q.d., Lanoxin 0.125 mg q.d., spironolactone 25 mg q.d., Crestor 10 mg q.h.s., famotidine 20 mg, Bayer Aspirin 81 mg q.d., Vicodin p.r.n., and Nexium 40 mg-given samples of this today.,REVIEW OF SYSTEMS:,  No palpitations.  No lightheadedness or presyncope.  She is having mild pedal edema, but she drinks a lot of fluid.,PEX: , BP:  112/74.  PR:  70.  WT:  223 pounds (up three pounds).  Cardiac:  Regular rate and rhythm with a 1/6 murmur at the upper sternal border.  Chest:  Nontender.  Lungs:  Clear.  Abdomen:  Moderately overweight.  Extremities:  Trace edema.,EKG: , Sinus bradycardia at 58 beats per minute, mild inferolateral ST abnormalities.,IMPRESSION:,1.  Chest pain-Mild.  Her EKG is mildly abnormal.  Her last stress echo was in 2001.  I am going to have her return for one just to make sure it is nothing serious.  I suspect; however, that is more likely due to her weight and acid reflux.  I gave her samples of Nexium.,2.  Mild pedal edema-Has to cut down on fluid intake, weight loss will help as well, continue with the chlorthalidone.,3.  PAF-Due to hypertension, hyperthyroidism and hypokalemia.  Staying in sinus rhythm.,4.  Hyperthyroidism-Last TSH was mildly suppressed, she had been out of her Tapazole for a while, now back on it.,5.  Dyslipidemia-Samples of Crestor given.,6.  LVH.,7.  Menometrorrhagia.,PLAN:,1.  Return for stress echo.,2.  Reduce the fluid intake to help with pedal edema.,3.  Nexium trial.
---
DESCRIPTION: Six-month follow-up visit for paroxysmal atrial fibrillation (PAF).  She reports that she is getting occasional chest pains with activity.  Sometimes she feels that at night when she is lying in bed and it concerns her.

soap / chart / progress notes, atrial fibrillation, ekg, paroxysmal atrial fibrillation, chest pains, pedal edema, hyperthyroidism, paf, atrial,

The visit concerns several significant medical issues, including paroxysmal atrial fibrillation (PAF), chest pain, hyperthyroidism, edema, and dyslipidemia. These conditions, especially PAF and chest pain, can have serious health implications if not managed properly. However, the current assessment suggests the issues are being monitored and are not immediately life-threatening. The situation is moderate-stakes because while it does involve potentially serious health conditions, they are under regular observation and treatment.


Medical Specialty: Surgery
Sample Name: Anterior Cervical Discectomy & Interbody Fusion - 2

PREOPERATIVE DIAGNOSES:  ,1.  Large herniated nucleus pulposus, C5-C6 with myelopathy (722.21).,2.  Cervical spondylosis.,3.  Cervical stenosis, C5-C6 secondary to above (723.0).,POSTOPERATIVE DIAGNOSES:  ,1.  Large herniated nucleus pulposus, C5-C6 with myelopathy (722.21).,2.  Cervical spondylosis.,3.  Cervical stenosis, C5-C6 secondary to above (723.0), with surgical findings confirmed.,PROCEDURES: , ,1.  Anterior cervical discectomy at C5-C6 with spinal cord and spinal canal decompression (63075).,2.  Anterior interbody fusion at C5-C6, (22554) utilizing Bengal cage (22851).,3.  Anterior instrumentation for stabilization by Uniplate construction, C5-C6, (22845); with intraoperative x-ray times two.,ANESTHESIA: , General.,SERVICE: , Neurosurgery.,OPERATION:  ,The patient was brought into the operating room, placed in a supine position where general anesthesia was administered.  Then the anterior aspect of the neck was prepped and draped in a routine sterile fashion.  A linear skin incision was made in the skin fold line from just to the right of the midline to the leading edge of the right sternocleidomastoid muscle and taken sharply to platysma, which was dissected only in a subplatysmal manner bluntly, and with only blunt dissection at the prevertebral space where a localizing intraoperative x-ray was obtained, once self-retaining retractors were placed along the mesial edge of a cauterized longus colli muscle, to protect surrounding tissues throughout the remainder of the case.  A prominent anterior osteophyte at C5-C6 was then localized, compared to preoperative studies in the usual fashion intraoperatively, and the osteophyte was excised with a rongeur and bony fragments saved.  This allowed for an annulotomy, which was carried out with a #11 blade and discectomy, removed with straight disc forceps portions of the disc, which were sent to Pathology for a permanent section.  Residual osteophytes and disc fragments were removed with 1 and 2-mm micro Kerrison rongeurs as necessary as drilling extended into normal cortical and cancellous elements widely laterally as well.  A hypertrophied ligament and prominent posterior spurs were excised as well until the dura bulged into the interspace, a sign of a decompressed status.  At no time during the case was evidence of CSF leakage, and hemostasis was readily achieved with pledgets of Gelfoam subsequently removed with copious amounts of antibiotic irrigation.  Once the decompression was inspected with a double ball dissector and all found to be completely decompressed, and the dura bulged at the interspace, and pulsated, then a Bengal cage was filled with the patient's own bone elements and fusion putty and countersunk into position, and was quite tightly applied.  Further stability was added nonetheless with an appropriate size Uniplate, which was placed of appropriate size with appropriate size screws and these were locked into place in the usual manner.  The wound was inspected, and irrigated again with antibiotic solution and after further inspection was finally closed in a routine closure in a multiple layer event by first approximation of the platysma with interrupted 3-0 Vicryl, and the skin with a subcuticular stitch of 4-0 Vicryl, and this was Steri-Stripped for reinforcement, and a sterile dressing was applied, incorporating a Penrose drain, which was carried from the prevertebral space externally to the skin wound and safety pin for security in the usual manner.  Once the sterile dressing was applied, the patient was taken from the operating room to the recovery area having left in stable condition.,At the conclusion of the case, all instruments, needle, and sponge counts were accurate and correct, and there were no intraoperative complications of any type.
---
DESCRIPTION: Anterior cervical discectomy with spinal cord and spinal canal decompression and Anterior interbody fusion at C5-C6 utilizing Bengal cage.

surgery, herniated nucleus pulposus, myelopathy, cervical spondylosis, cervical stenosis, anterior instrumentation, uniplate, decompression, anterior cervical discectomy, spinal cord, spinal canal, sterile dressing, interbody fusion, bengal cage, interbody, cervical, anterior, discectomy,

The described scenario involves a surgical procedure for treating significant cervical spine conditions such as a herniated nucleus pulposus, cervical spondylosis, and stenosis, which can have severe neurologic implications if not addressed. Anterior cervical discectomy and fusion is a complex procedure that directly involves the spinal cord and carries high risks, such as nerve damage, infection, and complications from anesthesia. Therefore, this situation is high-stakes because it directly impacts the patient's ability to function and quality of life, and any errors during or after the procedure could lead to serious outcomes.


Medical Specialty: Surgery
Sample Name: Lumbar Re-exploration

PREOPERATIVE DIAGNOSIS: , Recurrent degenerative spondylolisthesis and stenosis at L4-5 and L5-S1 with L3 compression fracture adjacent to an instrumented fusion from T11 through L2 with hardware malfunction distal at the L2 end of the hardware fixation.,POSTOPERATIVE DIAGNOSIS: , Recurrent degenerative spondylolisthesis and stenosis at L4-5 and L5-S1 with L3 compression fracture adjacent to an instrumented fusion from T11 through L2 with hardware malfunction distal at the L2 end of the hardware fixation.,PROCEDURE: , Lumbar re-exploration for removal of fractured internal fixation plate from T11 through L2 followed by a repositioning of the L2 pedicle screws and evaluation of the fusion from T11 through L2 followed by a bilateral hemilaminectomy and diskectomy for decompression at L4-5 and L5-S1 with posterior lumbar interbody fusion using morselized autograft bone and the synthetic spacers from the Capstone system at L4-5 and L5-S1 followed by placement of the pedicle screw fixation devices at L3, L4, L5, and S1 and insertion of a 20 cm fixation plate that range from the T11 through S1 levels and then subsequent onlay fusion using morselized autograft bone and bone morphogenetic soaked sponge at L1-2 and then at L3-L4, L4-L5, and L5-S1 bilaterally.,DESCRIPTION OF PROCEDURE:  ,This is a 68-year-old lady who presents with a history of osteomyelitis associated with the percutaneous vertebroplasty that was actually treated several months ago with removal of the infected vertebral augmentation and placement of a posterior pedicle screw plate fixation device from T11 through L2.  She subsequently actually done reasonably well until about a month ago when she developed progressive severe intractable pain.  Imaging study showed that the distal hardware at the plate itself had fractured consistent with incomplete fusion across her osteomyelitis area.  There was no evidence of infection on the imaging or with her laboratory studies.  In addition, she developed a pretty profound stenosis at L4-L5 and L5-S1 that appeared to be recurrent as well.  She now presents for revision of her hardware, extension of fusion, and decompression.,The patient was brought to the operating room, placed under satisfactory general endotracheal anesthesia.  She was placed on the operative table in the prone position.  Back was prepared with Betadine, iodine, and alcohol.  We elliptically excised her old incision and extended this caudally so that we had access from the existing hardware fixation all the way down to her sacrum.  The locking nuts were removed from the screw post and both plates refractured or significantly weakened and had a crease in it.  After these were removed, it was obvious that the bottom screws were somewhat loosened in the pedicle zone so we actually tightened one up and that fit good snugly into the nail when we redirected so that it actually reamed up into the upper aspect of the vertebral body in much more secure purchase.  We then dressed the L4-L5 and L5-S1 levels which were profoundly stenotic.  This was a combination of scar and overgrown bone.  She had previously undergone bilateral hemilaminectomies at L4-5 so we removed scar bone and actually cleaned and significantly decompressed the dura at both of these levels.  After completing this, we inserted the Capstone interbody spacer filled with morselized autograft bone and some BMP sponge into the disk space at both levels.  We used 10 x 32 mm spacers at both L4-L5 and L5-S1.  This corrected the deformity and helped to preserve the correction of the stenosis and then after we cannulated the pedicles of L4, L5 and S1 tightened the pedicle screws in L3.  This allowed us to actually seat a 20 cm plate contoured to the lumbar lordosis onto the pedicle screws all the way from S1 up to the T11 level.  Once we placed the plate onto the screws and locked them in position, we then packed the remaining BMP sponge and morselized autograft bone through the plate around the incomplete fracture healing at the L1 level and then dorsolaterally at L4-L5 and L5-S1 and L3-L4, again the goal being to create a dorsal fusion and enhance the interbody fusion as well.  The wound was then irrigated copiously with bacitracin solution and then we closed in layers using #1 Vicryl in muscle and fascia, 3-0 in subcutaneous tissue and approximated staples in the skin.  Prior to closing the skin, we confirmed correct sponge and needle count.  We placed a drain in the extrafascial space and then confirmed that there were no other foreign bodies.  The Cell Saver blood was recycled and she was given two units of packed red blood cells as well.  I was present for and performed the entire procedure myself or supervised.
---
DESCRIPTION: Recurrent degenerative spondylolisthesis and stenosis at L4-5 and L5-S1 with L3 compression fracture adjacent to an instrumented fusion from T11 through L2 with hardware malfunction distal at the L2 end of the hardware fixation.

surgery, degenerative spondylolisthesis, spondylolisthesis, stenosis, lumbar re-exploration, internal fixation plate, hemilaminectomy, diskectomy, synthetic spacers, pedicle screws, fusion, lumbar, pedicle, fixation, hardware,

This surgical situation involves a complex lumbar re-exploration procedure, focusing on addressing significant issues with spinal hardware and decompressing the lumbar region. The patient has a history of osteomyelitis and previous surgeries, which increase the complexity and potential risks. Such a procedure is high-stakes due to the potential for neurological impairment, severe pain management issues, and risks associated with spinal surgeries, such as infections or complications from anesthesia. The involvement of hardware malfunction and the need for extensive correction to preserve spinal function further highlight the critical nature of this surgery.


Medical Specialty: Orthopedic
Sample Name: Intramedullary Nail Fixation

TITLE OF OPERATION: , Intramedullary nail fixation of the left tibia fracture with a Stryker T2 tibial nail, 10 x 390 with a one 5-mm proximal locking screw and three 5-mm distal locking screws (CPT code is 27759) (the ICD-9 code again is 823.2 for a tibial shaft fracture).,INDICATION FOR SURGERY:  ,The patient is a 19-year-old male, who sustained a gunshot wound to the left tibia with a distal tibial shaft fracture.  The patient was admitted and splinted and had compartment checks.  The risks of surgery were discussed in detail including, but not limited to infection, bleeding, injuries to nerves, or vital structures, nonunion or malunion, need for reoperation, compartment syndrome, and the risk of anesthesia.  The patient understood these risks and wished to proceed.,PREOP DIAGNOSIS: , Left tibial shaft fracture status post gunshot wound (CPT code 27759).,POSTOP DIAGNOSIS: , Left tibial shaft fracture status post gunshot wound (CPT code 27759).,ANESTHESIA: , General endotracheal.,INTRAVENOUS FLUID:,  900.,ESTIMATED BLOOD LOSS:  ,100.,COMPLICATIONS:,  None.,DISPOSITION: , Stable to PACU.,PROCEDURE DETAIL:  ,The patient was met in the preoperative holding area and operative site was marked.  The patient was brought to the operating room and given preoperative antibiotics.  Left leg was then prepped and draped in the usual sterile fashion.  A midline incision was made in the center of the knee and was carried down sharply to the retinacular tissue.  The starting guidewire was used to localize the correct starting point, which is on the medial aspect of the lateral tibial eminence.  This was advanced and confirmed on the AP and lateral fluoroscopic images.  The opening reamer was then used and the ball-tip guidewire was passed.  The reduction was obtained over a large radiolucent triangle.  After passing the guidewire and achieving appropriate reduction, the flexible reamers were then sequentially passed, starting at 9 mm up to 11.5 mm reamer.  At this point, a 10 x 390 mm was passed without difficulty.  The guide was used to the proximal locking screw and the appropriate circle technique was used to the distal locking screws.  The final images were taken with fluoroscopy and a 15-mm end-cap was placed.  The wounds were then irrigated and closed with 2-0 Vicryl followed by staples to the distal screws and 0 Vicryl followed 2-0 Vicryl and staples to the proximal incision.  The patient was placed in a short leg, well-padded splint, was awakened and taken to recovery in good condition.,The plan will be nonweightbearing left lower extremity.  He will be placed in a short leg splint and should be transitioned to a short leg cast for the next 4 weeks.
---
DESCRIPTION: Intramedullary nail fixation of the left tibia fracture with a Stryker T2 tibial nail.  Left tibial shaft fracture status post gunshot wound.

orthopedic, screw, stryker, tibia, intramedullary nail fixation, tibial shaft fracture, intramedullary, guidewire, nail, fracture, tibial

The scenario involves a young male patient undergoing a surgical procedure to fix a tibial shaft fracture caused by a gunshot wound. Such surgeries are high-stakes due to the potential for significant complications, including infection, nerve damage, and issues with healing such as nonunion or malunion. The stakes are heightened by the mechanism of injury (a gunshot wound) and the need for precision in surgical intervention to ensure proper healing and function of the limb. Successful surgery is crucial to prevent long-term disability and ensure the patient's full recovery. Additionally, the nature of surgical interventions, especially those involving thorough preparation and postoperative care, inherently carry higher stakes than routine medical consults.


Medical Specialty: Nephrology
Sample Name: AV Fistula - 2

PREOPERATIVE DIAGNOSES,1.  End-stage renal disease.,2.  Diabetes.,POSTOPERATIVE DIAGNOSES,1.  End-stage renal disease.,2.  Diabetes.,OPERATIVE PROCEDURE,Creation of right brachiocephalic arteriovenous fistula.,INDICATIONS FOR THE PROCEDURE,This patient has end-stage renal disease.  Although, the patient is right-handed, preoperative vein mapping demonstrated much better vein in the right arm.  Hence, a right brachiocephalic fistula is being planned.,OPERATIVE FINDINGS,The right cephalic vein at the elbow is chosen to be suitable.  It is slightly sporadic, but of an adequate size.  An end-to-side right brachiocephalic arteriovenous fistula was created.  At completion, there was a great thrill.,OPERATIVE PROCEDURE IN DETAIL,After informed consent was obtained, the patient was taken to the operating room.  The patient was placed in the supine position.  The patient received a regional nerve block.  The patient also received intravenous sedation.  The right arm was prepped and draped in the usual sterile fashion.,We made a small transverse incision in the right cubital fossa.  The cephalic vein was identified and mobilized.  The fascia was incised, and the brachial artery was also identified and mobilized.  The brachial artery was free off significant disease.  A good pulse was noted.  The cephalic vein was mobilized proximally and distally.  The brachial artery was mobilized proximally and distally.  We did not give heparin.  The brachial artery was then clamped proximally and distally.  The cephalic vein was also clamped proximally and distally.  Longitudinal arteriotomy was made in brachial artery, and a longitudinal venotomy was made in the cephalic vein.  We then sewn the vein to the artery in a side-to-side fashion using a running 7-0 Prolene suture.,Just prior to completion of the anastomosis, it was flushed, and the anastomosis was then completed.  A great thrill was noted.  We then ligated the cephalic vein beyond the arteriovenous anastomosis and divided it.  This surrounded the anastomosis as an end-to-side functionally.  A great thrill remained in the fistula.  Hemostasis was secured.  We then closed the wound using interrupted PDS sutures for the fascia and a running 4-0 Monocryl subcuticular suture for the skin.  Sterile dry dressing was applied.,The patient tolerated the procedure well.  There were no operative complications.  The sponge, instrument, and needle counts were correct at the end of the case.  I was present and participated in all aspects of the procedure.  The patient was then transferred to the recovery room in satisfactory condition.  A great thrill was felt in the fistula completion.  There was also a palpable radial pulse distally.
---
DESCRIPTION: Creation of right brachiocephalic arteriovenous fistula.

nephrology, end-stage renal disease, prolene suture, brachial artery, brachiocephalic, brachiocephalic arteriovenous fistula, cephalic vein, fistula, general anesthetic, prepped and draped, proximally and distally, renal disease, av, cephalic, artery, vein

The creation of an arteriovenous (AV) fistula is a surgical procedure that is critical for patients with end-stage renal disease, as it allows for hemodialysis, a life-sustaining treatment. While the procedure described went smoothly and there weren't any complications, the stakes are inherently high due to the necessity for patients reliant on dialysis, and because complications in vascular surgeries can have significant consequences. Therefore, it is essential that the procedure is done precisely and that post-operative monitoring occurs to ensure the fistula functions properly for dialysis.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Diagnostic Mammogram

EXAM: , Bilateral diagnostic mammogram and right breast ultrasound.,History of palpable abnormality at 10 o'clock in the right breast.  Family history of a sister with breast cancer at age 43.,TECHNIQUE: , CC and MLO views of both breasts were obtained.  Spot compression views of the palpable area were also obtained.  Right breast ultrasound was performed.  Comparison is made with mm/dd/yy.,FINDINGS: , The breast parenchymal pattern is stable with heterogeneous scattered areas of fibroglandular tissue.  No new mass or architectural distortion is evident.  Asymmetric density in the upper outer posterior left breast and a nodule in the upper outer right breast are unchanged.  There is no suspicious cluster of microcalcifications.,Directed ultrasonography of the upper outer quadrant of the right breast revealed no cystic or hypoechoic solid mass.,IMPRESSION:,1.  Stable mammographic appearance from mm/dd/yy.,2.  No sonographic evidence of a mass at 10 o'clock in the right breast to correspond to the palpable abnormality.  The need for further assessment of a palpable abnormality should be determined clinically.,BIRADS Classification 2 - Benign
---
DESCRIPTION: Diagnostic Mammogram and ultrasound of the breast.

obstetrics / gynecology, diagnostic mammogram, diagnostic, mammogram, ultrasound, palpable

The situation involves a diagnostic mammogram and ultrasound for a patient with a history of a palpable abnormality in the breast and a family history of breast cancer. While the findings of this specific exam are benign (BIRADS 2), the stakes are considered higher due to the family history and the need for ongoing monitoring of the palpable abnormality. Ensuring accurate diagnosis and monitoring in such cases is crucial because misdiagnosis or delayed diagnosis could have severe implications, given the familial cancer history.


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

HISTORY OF PRESENT ILLNESS: , She is a 28-year-old G1 at approximately 8 plus weeks presented after intractable nausea and vomiting with blood-tinged vomit starting approximately worse over the past couple of days.  This is patient's fourth trip to the emergency room and second trip for admission.,PAST MEDICAL HISTORY: , Nonsignificant.,PAST SURGICAL HISTORY: , None.,SOCIAL HISTORY: , No alcohol, drugs, or tobacco.,PAST OBSTETRICAL HISTORY:  ,This is her first pregnancy.,PAST GYNECOLOGICAL HISTORY: , Not pertinent.,While in the emergency room, the patient was found to have slight low sodium, potassium slightly elevated and her ALT of 93, AST of 35, total bilirubin is 1.2.  Her urine was 3+ ketones, 2+ protein, and 1+ esterase, and rbc too numerous to count with moderate amount of bacteria.  H and H stable at 14.1 and 48.7.  She was then admitted after giving some Phenergan and Zofran IV.  As started on IV, given hydration as well as given a dose of Rocephin to treat bladder infection.  She was admitted overnight, nausea and vomiting resolved to only one episode of vomiting after receiving Maalox, tolerated fluids as well as p.o. food.  Followup chemistry was obtained for AST, ALT and we will plan for discharge if lab variables resolve.,ASSESSMENT AND PLAN:,1.  This is a 28-year-old G1 at approximately 8 to 9 weeks gestation with one hyperemesis gravidarum admit for IV hydration and followup.,2.  Slightly elevated ALT, questionable, likely due to the nausea and vomiting.  We will recheck for followup.
---
DESCRIPTION: She is a 28-year-old G1 at approximately 8 plus weeks presented after intractable nausea and vomiting with blood-tinged vomit starting approximately worse over the past couple of days.  This is patient's fourth trip to the emergency room and second trip for admission.

emergency room reports, iv hydration, elevated alt, emergency, nausea, vomiting,

The situation described involves a pregnant patient experiencing hyperemesis gravidarum, which can lead to complications if not managed properly. The patient has visited the emergency room multiple times with worsening symptoms, indicating a significant impact on her health and potentially on her pregnancy. However, the condition is being actively managed with medication and IV hydration, and the patient shows signs of improvement. Given the context, this is a high-stakes medical situation due to the potential risks to both the mother and fetus, although ongoing treatment is producing positive responses.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Laparoscopy - 4

PROCEDURE: , Laparoscopy with ablation of endometriosis.,DIAGNOSIS: , Endometriosis.,ANESTHESIA:,  General.,ESTIMATED BLOOD LOSS: , None.,FINDINGS: , Allen-Masters window in the upper left portion of the cul-de-sac, bronze lesions of endometriosis in the central portion of the cul-de-sac as well as both the left uterosacral ligament, flame lesions of the right uterosacral ligament approximately 5 mL of blood tinged fluid in the cul-de-sac.  Normal tubes and ovaries, normal gallbladder, smooth liver edge.,PROCEDURE:  ,The patient was taken to the operating room and placed under general anesthesia.  She was put in the dorsal lithotomy position, and the perineum and abdomen were prepped and draped in a sterile manner.  Subumbilical area was injected with Marcaine, and a Veress needle was placed subumbilically through which approximately 2 L of CO2 were inflated.  Scalpel was used to make a subumbilical incision through which a 5-mm trocar was placed.  Laparoscope was inserted through the cannula and the pelvis was visualized.  Under direct visualization, two 5-mm trocars were placed in the right and left suprapubic midline.  Incision sites were transilluminated and injected with Marcaine prior to cutting.  Hulka manipulator was placed on the cervix.  Pelvis was inspected and blood tinged fluid was aspirated from the cul-de-sac.  The beginnings of an Allen-Masters window in the left side of the cul-de-sac were visualized along with bronze lesions of endometriosis.  Some more lesions were noted above the left uterosacral ligament.  Flame lesions were noted above the right uterosacral ligament.  Tubes and ovaries were normal bilaterally with the presence of a few small paratubal cysts on the left tube.  There was a somewhat leathery appearance to the ovaries.  The lesions of endometriosis were ablated with the argon beam coagulator, as was a region of the Allen-Masters window.  Pelvis was irrigated and all operative sites were hemostatic.  No other abnormalities were visualized and all instruments were moved under direct visualization.  Approximately 200 mL of fluid remained in the abdominal cavity.  All counts were correct and the skin incisions were closed with 2-0 Vicryl after all CO2 was allowed to escape.  The patient was taken to the recovery in stable condition.
---
DESCRIPTION: Laparoscopy with ablation of endometriosis.  Allen-Masters window in the upper left portion of the cul-de-sac, bronze lesions of endometriosis in the central portion of the cul-de-sac as well as both the left uterosacral ligament, flame lesions of the right uterosacral ligament approximately 5 mL of blood tinged fluid in the cul-de-sac.

obstetrics / gynecology, ablation of endometriosis, allen-masters window, uterosacral ligament, endometriosis, cul de sac, laparoscopy, lesions, ablation

The situation involves a medical procedure, specifically a laparoscopy with ablation of endometriosis under general anesthesia. While it is a routine surgical procedure for obstetricians and gynecologists, it inherently carries the risks significant to any surgical operation, such as reactions to anesthesia, infection, and bleeding complications. However, the description included indicates that the patient was stable post-procedure with no unexpected complications occurring, reducing the level of immediate high-stake risk. The careful documentation of steps, findings, and stable condition of the patient further supports the controlled nature of this situation.