Medical Specialty: General Medicine
Sample Name: Gen Med Consult - 10

CHIEF COMPLAINT:,  Joints are hurting all over and checkup.,HISTORY OF PRESENT ILLNESS:,  A 77-year-old white female who is having more problems with joint pain.  It seems to be all over decreasing her mobility, hands and wrists.  No real swelling but maybe just a little more uncomfortable than they have been.  The Daypro generic does not seem to be helping at all.  No fever or chills.  No erythema.,She actually is doing better.  Her diarrhea now has settled down and she is having less urinary incontinence, less pedal edema.  Blood sugars seem to be little better as well.,The patient also has gotten back on her Zoloft because she thinks she may be depressed, sleeping all the time, just not herself and really is disturbed that she cannot be more mobile in things.  She has had no polyuria, polydipsia, or other problems.  No recent blood pressure checks.,PAST MEDICAL HISTORY:,  Little over a year ago, the patient was found to have lumbar discitis and was treated with antibiotics and ended up having debridement and instrumentation with Dr. XYZ and is doing really quite well.  She had a pulmonary embolus with that hospitalization.,PAST SURGICAL HISTORY:,  She has also had a hysterectomy, salpingoophorectomy, appendectomy, tonsillectomy, two carpal tunnel releases.  She also has had a parathyroidectomy but still has had some borderline elevated calcium.  Also, hypertension, hyperlipidemia, as well as diabetes.  She also has osteoporosis.,SOCIAL HISTORY:,  The patient still smokes about a third of a pack a day, also drinks only occasional alcoholic drinks.  The patient is married.  She has three grown sons, all of which are very successful in professional positions.  One son is a gastroenterologist in San Diego, California.,MEDICATIONS:,  Nifedipine-XR 90 mg daily, furosemide 20 mg half tablet b.i.d., lisinopril 20 mg daily, gemfibrozil 600 mg b.i.d., Synthroid 0.1 mg daily, Miacalcin one spray in alternate nostrils daily, Ogen 0.625 mg daily, Daypro 600 mg t.i.d., also Lortab 7.5 two or three a day, also Flexeril occasionally, also other vitamin.,ALLERGIES: , She had some adverse reactions to penicillin, sulfa, perhaps contrast medium, and some mycins.,FAMILY HISTORY:,  As far as heart disease there is none in the family.  As far as cancer two cousins had breast cancer.  As far as diabetes father and grandfather had type II diabetes.  Son has type I diabetes and is struggling with that at the moment.,REVIEW OF SYSTEMS:,General:  No fever, chills, or night sweats.  Weight stable.,HEENT:  No sudden blindness, diplopia, loss of vision, i.e., in one eye or other visual changes.  No hearing changes or ear problems.  No swallowing problems or mouth lesions.,Endocrine:  Hypothyroidism but no polyuria or polydipsia.  She watches her blood sugars.  They have been doing quite well.,Respiratory:  No shortness of breath, cough, sputum production, hemoptysis or breathing problems.,Cardiovascular:  No chest pain or chest discomfort.  No paroxysmal nocturnal dyspnea, orthopnea, palpitations, or heart attacks.,GI:  As mentioned, has had diarrhea though thought to be possibly due to Clostridium difficile colitis that now has gotten better.  She has had some irritable bowel syndrome and bowel abnormalities for years.,GU:  No urinary problems, dysuria, polyuria or polydipsia, kidney stones, or recent infections.  No vaginal bleeding or discharge.,Musculoskeletal:  As above.,Hematological:  She has had some anemia in the past.,Neurological:  No blackouts, convulsions, seizures, paralysis, strokes, or headaches.,PHYSICAL EXAMINATION:,Vital Signs:  Weight is 164 pounds.  Blood pressure:  140/64.  Pulse:  72.  Blood pressure repeated by me with the patient sitting taken on the right arm is 148/60, left arm 136/58; these are while sitting on the exam table.,General:  A well-developed pleasant female who is comfortable in no acute distress otherwise but she does move slowly.,HEENT:  Skull is normocephalic.  TMs intact and shiny with good auditory acuity to finger rub.  Pupils equal, round, reactive to light and accommodation with extraocular movements intact.  Fundi benign.  Sclerae and conjunctivae were normal.,Neck:  No thyromegaly or cervical lymphadenopathy.  Carotids are 2+ and equal bilaterally and no bruits present.,Lungs:  Clear to auscultation and percussion with good respiratory movement.  No bronchial breath sounds, egophony, or rales are present.,Heart:  Regular rhythm and rate with no murmurs, gallops, rubs, or enlargement.  PMI normal position.  All pulses are 2+ and equal bilaterally.,Abdomen:  Obese, soft with no hepatosplenomegaly or masses.,Breasts:  No predominant masses, discharge, or asymmetry.,Pelvic Exam:  Normal external genitalia, vagina and cervix.  Pap smear done.  Bimanual exam shows no uterine enlargement and is anteroflexed.  No adnexal masses or tenderness.  Rectal exam is normal with soft brown stool Hemoccult negative.,Extremities:  The patient does appear to have some doughiness of all of the MCP joints of the hands and the wrists as well.  No real erythema.  There is no real swelling of the knees.  No new pedal edema.,Lymph nodes:  No cervical, axillary, or inguinal adenopathy.,Neurological:  Cranial nerves II-XII are grossly intact.  Deep tendon reflexes are 2+ and equal bilaterally.  Cerebellar and motor function intact in all extremities.  Good vibratory and positional sense in all extremities and dermatomes.  Plantar reflexes are downgoing bilaterally.,LABORATORY:  ,CBC shows a hemoglobin of 10.5, hematocrit 35.4, otherwise normal.  Urinalysis is within normal limits.  Chem profile showed a BUN of 54, creatinine 1.4, glucose 116, calcium was 10.8, cholesterol 198, triglycerides 171, HDL 43, LDL 121, TSH is normal, hemoglobin A1C is 5.3.,ASSESSMENT:,1.  Arthralgias that are suspicious for inflammatory arthritis, but certainly seems to be more active and bothersome.  I think we need to look at this more closely.,2.  Diarrhea that seems to have resolved.  Whether this is related to the above is unclear.,3.  Diabetes mellitus type II, really fairly well controlled.
---
DESCRIPTION: Checkup - Joints hurting all over - Arthralgias that are suspicious for inflammatory arthritis.

The patient is experiencing widespread joint pain which is negatively impacting her mobility and quality of life, raising the suspicion of inflammatory arthritis. This condition is significant and requires attention but is not life-threatening in the immediate sense. The patient has a history of multiple complex medical conditions, including Type II diabetes, pulmonary embolism, and osteoporosis, adding a layer of complexity to her overall health management. However, there are no immediate life-threatening symptoms like chest pain or severe respiratory distress presented in this consultation.


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

Medical Specialty: Nephrology
Sample Name: CT Abdomen & Pelvis - 1

EXAM: , CT Abdomen and Pelvis with contrast ,REASON FOR EXAM:, Nausea, vomiting, diarrhea for one day.  Fever.  Right upper quadrant pain for one day.  ,COMPARISON: , None. ,TECHNIQUE:,  CT of the abdomen and pelvis performed without and with approximately 54 ml Isovue 300 contrast enhancement.  ,CT ABDOMEN: , Lung bases are clear.  The liver, gallbladder, spleen, pancreas, and bilateral adrenal/kidneys are unremarkable.  The aorta is normal in caliber.  There is no retroperitoneal lymphadenopathy.  ,CT PELVIS: , The appendix is visualized along its length and is diffusely unremarkable with no surrounding inflammatory change.  Per CT, the colon and small bowel are unremarkable.  The bladder is distended.  No free fluid/air.  Visualized osseous structures demonstrate no definite evidence for acute fracture, malalignment, or dislocation.,IMPRESSION:,1.  Unremarkable exam; specifically no evidence for acute appendicitis. ,2.  No acute nephro-/ureterolithiasis. ,3.  No secondary evidence for acute cholecystitis.,Results were communicated to the ER at the time of dictation.
---
DESCRIPTION: CT Abdomen and Pelvis with contrast

CT Abdomen and Pelvis with contrast

nephrology, liver, gallbladder, spleen, pancreas, adrenal, kidneys, lymphadenopathy, abdomen and pelvis, contrast, ct

The CT scan results show that there is no acute medical condition such as appendicitis or nephrolithiasis, and the relevant organs are unremarkable, meaning there are no acute findings that usually require immediate intervention. The patient has symptoms that prompted the scan, but the results do not indicate an urgent medical crisis. Therefore, the situation is not considered high-stakes from a critical health intervention perspective.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Consult - History and Phy.
Sample Name: Cardiac Consultation - 3

HISTORY OF PRESENT ILLNESS:, The patient is known to me secondary to atrial fibrillation with slow ventricular response, partially due to medications, at least when I first saw him in the office on 01/11/06. He is now 77 years old. He is being seen on the Seventh Floor. The patient is in Room 7607. The patient has a history of recent adenocarcinoma of the duodenum that was found to be inoperable, since it engulfed the porta hepatis. The workup began with GI bleeding. He was seen in my office on 01/11/06 for preop evaluation due to leg edema. A nonocclusive DVT was diagnosed in the proximal left superficial femoral vein. Both legs were edematous, and bilateral venous insufficiency was also present. An echocardiogram demonstrated an ejection fraction of 50%. The patient was admitted to the hospital and treated with a Greenfield filter since anticoagulant was contraindicated. Additional information on the echocardiogram, where a grossly dilated left atrium, moderately severely dilated right atrium. The rhythm was, as stated before, atrial fibrillation with slow atrioventricular conduction and an intraventricular conduction delay on the monitor strip. There was mild to moderate tricuspid regurgitation, mild pulmonic insufficiency. The ejection fraction was considered low normal, since it was estimated 50 to 54%. The patient received blood while in the hospital due to anemia. The leg edema improved while lying down, suggesting that the significant element of venous insufficiency was indeed present. The patient, who was diabetic, received consultation by Dr. R. He was also a chronic hypertensive and was treated for that with ACE inhibitors. The atrial fibrillation was slow, and no digitalis or beta blockers were recommended at the same time. As a matter of fact, they were discontinued. Now, the patient denied any shortness of breath or chest pain throughout this hospitalization, and cardiac nuclear studies performed earlier demonstrated no reversible ischemia.,ALLERGIES:, THE PATIENT HAS NO KNOWN DRUG ALLERGIES.,His diabetes was suspected to be complicated with neuropathy due to tingling in both feet. He received his immunizations with flu in 2005 but did not receive Pneumovax.,SOCIAL HISTORY:, The patient is married. He had 1 child who died at the age of 26 months of unknown etiology. He quit smoking 6 years ago but dips (smokeless) tobacco.,FAMILY HISTORY:, Mother had cancer, died at 70. Father died of unknown cause, and brother died of unknown cause.,FUNCTIONAL CAPACITY:, The patient is wheelchair bound at the time of his initial hospitalization. He is currently walking in the corridor with assistance. Nocturia twice to 3 times per night.,REVIEW OF SYSTEMS:,OPHTHALMOLOGIC: Uses glasses.,ENT: Complains of occasional sinusitis.,CARDIOVASCULAR: Hypertension and atrial fibrillation.,RESPIRATORY: Normal.,GI: Colon bleeding. The patient believes he had ulcers.,GENITOURINARY: Normal.,MUSCULOSKELETAL: Complains of arthritis and gout.,INTEGUMENTARY: Edema of ankles and joints.,NEUROLOGICAL: Tingling as per above. Denies any psychiatric problems.,ENDOCRINE: Diabetes, NIDDM.,HEMATOLOGIC AND LYMPHATIC: The patient does not use any aspirin or anticoagulants and is not of anemia.,LABORATORY:, Current EKG demonstrates atrial fibrillation with incomplete left bundle branch block pattern. Q waves are noticed in the inferior leads. Nonprogression of the R-wave from V1 to V4 with small R-waves in V5 and V6 are suggestive of an old anterior and inferior infarcts. Left ventilator hypertrophy and strain is suspected.,PHYSICAL EXAMINATION:,GENERAL: On exam, the patient is alert, oriented and cooperative. He is mildly pale. He is an elderly gentleman who is currently without diaphoresis, pallor, jaundice, plethora, or icterus.,VITAL SIGNS: Blood pressure is 159/69 with a respiratory rate of 20, pulse is 67 and irregularly irregular. Pulse oximetry is 100.,NECK: Without JVD, bruit, or thyromegaly. The neck is supple.,CHEST: Symmetric. There is no heave or retraction.,HEART: The heart sounds are irregular and no significant murmurs could be auscultated.,LUNGS: Clear to auscultation.,ABDOMEN: Exam was deferred.,LEGS: Without edema. Pulses: Dorsalis pedis pulse was palpated bilaterally.,MEDICATIONS:, Current medications include enalapril, low dose enoxaparin, Fentanyl patches. He is no longer on fluconazole. He is on a sliding scale as per Dr. Holden. He is on lansoprazole (Prevacid), Toradol, piperacillin/tazobactam, hydralazine p.r.n., Zofran, Dilaudid, Benadryl, and Lopressor p.r.n.,ASSESSMENT AND PLAN:, The patient is a very pleasant elderly gentleman with intractable/inoperable malignancy. His cardiac issues are chronic and most likely secondary to long term hypertension and diabetes. He has chronic atrial fibrillation. I do not envision a scenario whereby he will become a candidate for management of this arrhythmia beyond weight control. He is also not a candidate for anticoagulation, which is, in essence, a part and parcel of the weight control. Reason being is high likelihood for GI bleeding, especially given the diagnosis of invasive malignancy with involvement of multiple organs and lymph nodes. At this point, I agree with the notion of hospice care. If his atrioventricular conduction becomes excessive, occasional nondihydropyridine calcium channel blocker such as diltiazem or beta blockers would be appropriate; otherwise, I would keep him off those medications due to evidence of slow conduction in the presence of digitalis and beta blockers.
---
DESCRIPTION: Patient with atrial fibrillation with slow ventricular response, partially due to medications.

The situation involves a complex medical case of a 77-year-old patient with multiple serious health conditions including inoperable cancer, atrial fibrillation, diabetes, hypertension, and a history of GI bleeding. The patient is not a candidate for several standard treatments due to the risk of bleeding and other complications, and there is consideration for hospice care. Given the patient's age, multiple comorbidities, and the inoperability of the cancer, these are high-stakes decisions as they will significantly impact the patient's quality of life and care options. Additionally, the mention of moving towards hospice care indicates end-of-life considerations, further underscoring the gravity of the situation.


Medical Specialty: Orthopedic
Sample Name: Lumbar Laminotomy & Discectomy

PREOPERATIVE DIAGNOSIS:,  Herniated nucleus pulposus of L5-S1 on the left.,POSTOPERATIVE DIAGNOSIS: ,Herniated nucleus pulposus of L5-S1 on the left.,PROCEDURE PERFORMED:, Microscopic assisted lumbar laminotomy with discectomy at L5-S1 on the left.,ANESTHESIA: , General via endotracheal tube.,ESTIMATED BLOOD LOSS: , Less than 50 cc.,SPECIMENS: , Disc that was not sent to the lab.,DRAINS: , None.,COMPLICATIONS: , None.,SURGICAL PROGNOSIS: , Remains guarded due to her ongoing pain condition and Tarlov cyst at the L5 nerve root distally.,SURGICAL INDICATIONS: , The patient is a 51-year-old female who has had unrelenting low back pain that radiated down her left leg for the past several months.  The symptoms were unrelieved by conservative modalities.  The symptoms were interfering with all aspects of daily living and inability to perform any significant work endeavors.  She is understanding the risks, benefits, potential complications, as well as all treatment alternatives.  She wished to proceed with the aforementioned surgery due to her persistent symptoms.  Informed consent was obtained.,OPERATIVE TECHNIQUE: , The patient was taken to OR room #5 where she was given general anesthetic by the Department of Anesthesia.  She was subsequently placed on the Jackson spinal table with the Wilson attachment in the prone position.  Palpation did reveal the iliac crest and suspected L5-S1 interspace.  Thereafter the lumbar spine was serially prepped and draped.  A midline incision was carried over the spinal process of L5 to S1.  Skin and subcutaneous tissue were divided sharply.  Electrocautery provided hemostasis.  Electrocautery was then utilized to dissect through the subcutaneous tissues to the lumbar fascia.  Lumbar fascia was identified and the decussation of fibers was identified at the L5-S1 interspace.  On the left side, superior aspect dissection was carried out with the Cobb elevator and electrocautery.  This revealed the interspace of suspect level of L5-S1 on the left.  A Kocher clamp was placed between the spinous processes of the suspect level of L5-S1.  X-ray did confirm the L5-S1 interval.  Angled curet was utilized to detach the ligamentum flavum from its bony attachments at the superior edge of S1 lamina and the inferior edge of the L5 lamina.  Meticulous dissection was undertaken and the ligamentum flavum was removed.  Laminotomy was created with Kerrison rongeur, both proximally and distally.  The microscope was positioned and the dura was inspected.  A blunt Penfield elevator was then utilized to dissect and identify the L5-S1 nerve root on the left.  It was noted to be tented over a disc extrusion.  The nerve root was protected and medialized.  It was retracted with a nerve root retractor.  This did reveal a subligamentous disc herniation at approximately the L5-S1 disc space and neuroforaminal area.  A #15 Bard-Parker blade was utilized to create an annulotomy.  Medially, disc material was extruding through this annulotomy.  Two tier rongeur was then utilized to grasp the disc material and the disc was removed from the interspace.  Additional disc material was then removed, both to the right and left of the annulotomy.  Up and downbiting pituitary rongeurs were utilized to remove any other loose disc pieces.  Once this was completed, the wound was copiously irrigated with antibiotic solution and suctioned dry.  The Penfield elevator was placed in the disc space of L5-S1 and a crosstable x-ray did confirm this level.  Nerve root was again expected exhibiting the foramina.  A foraminotomy was created with a Kerrison rongeur.  Once this was created, the nerve root was again inspected and deemed free of tension.  It was mobile within the neural foramina.  The wound was again copiously irrigated with antibiotic solution and suctioned dry.  A free fat graft was then harvested from the subcutaneous tissues and placed over the exposed dura.  Lumbar fascia was then approximated with #1 Vicryl interrupted fashion, subcutaneous tissue with #2-0 Vicryl interrupted fashion, and #4-0 undyed Vicryl was utilized to approximate the skin.  Compression dressing was applied.  The patient was turned, awoken, and noted to be moving all four extremities without apparent deficits.  She was taken to the recovery room in apparent satisfactory condition.  Expected surgical prognosis remains guarded due to her ongoing pain syndrome that has been requiring significant narcotic medications.
---
DESCRIPTION: Microscopic assisted lumbar laminotomy with discectomy at L5-S1 on the left.  Herniated nucleus pulposus of L5-S1 on the left.

orthopedic, lumbar laminotomy with discectomy, microscopic assisted, herniated nucleus pulposus, subcutaneous tissue, ligamentum flavum, kerrison rongeur, penfield elevator, lumbar laminotomy, lumbar fascia, nerve root, discectomy, lumbar, laminotomy, herniated,

This situation involves a surgical procedure, which inherently carries potential risks and requires precise execution to ensure a successful outcome and minimize complications. The patient's ongoing pain condition and existing Tarlov cyst introduce additional complexity and uncertainty to the surgical prognosis. Moreover, any surgical intervention, particularly spinal surgeries, can significantly impact a patient's quality of life and their ability to perform daily and work activities, thus making it a high-stakes scenario.


Medical Specialty: IME-QME-Work Comp etc.
Sample Name: Occupational Medicine Consult - 2

ALLOWED CONDITIONS:,  726.31 right medial epicondylitis; 354.0 right carpal tunnel syndrome.,CONTESTED CONDITIONS:,  354.2 right cubital tunnel syndrome.,EMPLOYER:,  ABCD,  ,I examined Xxxxx today for the allowed conditions and also the contested conditions listed above.  I obtained her history from company medical records and performed an examination.  She is a 38-year-old laborer who states that she was injured on April 26, 2006, which according to the FROI (the injury occurred over a period of time from performing normal job processes such as putting bumpers on cars, gas caps and doors on cars).  She denies having any symptoms prior to the accident April 26, 2006.  She is right handed.  She used a tennis elbow brace, hand exercises, physical therapy, and Vicodin.  She received treatment from Dr. X and also Dr. Y,DIAGNOSTIC STUDIES:,  June 27, 2006, EMG and nerve conduction velocity right upper extremity showed a moderate right carpal tunnel syndrome.  No evidence of a right cervical radiculopathy or ulnar neuropathy at the wrist or elbow.  January 29, 2007, EMG right upper extremity was normal and there was a normal nerve conduction velocity.  At the time of the examination, she complained of a constant pain in the olecranon and distal triceps with tingling in the right long, ring and small fingers, and night pain.  The pain was accentuated by gripping or opening the jar.  She is taking four Aleve a day and currently does not have any other treatment.,RECORDS REVIEWED: , Injury and illness incident report, US Healthworks records; Z physician review; Y office notes; X office notes who noted that on examination of the right elbow that the ulnar nerve subluxed with flexion and extension of the elbow.,EXAMINATION: , Examination of her right elbow revealed no measurable atrophy of the upper arm.  She was markedly tender over the medial epicondyle, but also the olecranon and distal process and she was exquisitely tender over the ulnar nerve.  I did not detect subluxation of the ulnar nerve with flexion and extension.  With this, she was extremely tender in this area.  There is no instability of the elbow.  Range of motion was 0 to 145 degrees, flexion 90 degrees of pronation and supination.  The elbow flexion test was positive.  There is normal motor power in the elbow and also on the right hand, specifically in the ulnar intrinsics.  There was diminished sensation on the right ring and small fingers, specifically the ulnar side of the ring finger of the entire small finger.  There was no wasting of the intrinsics.  No clawing of the hand.  Examination of the right wrist revealed extension 45 degrees, flexion 45 degrees, radial deviation 15 degrees, and ulnar deviation 35 degrees.  She was tender over the dorsum of the hand over the ulnar head and the volar aspect of the wrist.  Wrist flexion causes paresthesias on the right ring and small fingers.  Grasp was weak.  There was no sign of causalgia, but no measurable atrophy of the forearm.  No reflex changes.,QUESTION:,  Ms. Xxxxx has filed an application of additional allowance of right cubital tunnel syndrome.  Based on the current objective findings, mechanism of injury, medical records or diagnostic studies, does the medical evidence support the existence of the requested condition?,ANSWER:,  Yes.  She has a positive elbow flexion test and she is markedly tender over the ulnar nerve at the elbow and also has diminished sensation in the ulnar nerve distribution, specifically in the entire right small finger and the ulnar half of the ring finger.  I did not find the subluxation of the ulnar nerve with flexion and extension with Dr. X did previously find on his examination.,QUESTION: , If you find these conditions exist, are they a direct and proximate result of April 26, 2006, injury?,ANSWER: , Yes.  Repeated flexion and extension would irritate the ulnar nerve particularly if it was subluxing which it could very well have which Dr. X objectively identified on his examination.  Therefore, I believe it is a direct and proximate result of April 26, 2006, injury.,QUESTION: , Do you find that Ms. Xxxxx's injury or disability is caused by natural deterioration of tissue, organ or part of the body?,ANSWER: , No.,QUESTION:,  In addition, if you find that the condition exists, are there non-occupational activities or intervening injuries that could have contributed to Ms. Xxxxx's condition?,ANSWER: , It is possible that direct injury to the ulnar nerve at the elbow could cause this syndrome; however, there is no history of this and the records do not indicate an injury of this type.,QUESTION: ,
---
DESCRIPTION: Occupational medicine consult with questions-answers and records review.

The described situation involves a medical evaluation within the context of occupational medicine, likely related to a legal or insurance claim about work-related injuries. While the stakes involve a worker's health and potential compensation or benefits, it does not involve immediate risk to life or urgent medical attention. Given the legal implications and the impact on the patient's work and personal life, this is moderately high stakes.


Medical Specialty: Consult - History and Phy.
Sample Name: Gen Med Consult - 26

CHIEF COMPLAINT:, Abdominal pain and discomfort for 3 weeks.,HISTORY OF PRESENT ILLNESS:, ,The patient is a 38 year old white female with no known medical problems who presents complaining of abdominal pain and discomfort for 3 weeks. She had been in her normal state of health when she started having this diffuse abdominal pain and discomfort which is mostly located in the epigastrium and right upper quadrant. She also complains of indigestion and right scapular pain during this same period. None of these complaints are alleviated or aggravated by food. She denies any NSAIDs use. The patient went to an outside hospital where a right upper quadrant ultrasound showed no gallbladder disease, but was suspicious for a liver mass. A CT and MRI of the abdomen and pelvis showed a 12.5 X 10.9 X 11.1 cm right suprarenal mass and a 7.1 X 5.4 X 6.5 cm intrahepatic mass in the region of the dome of the liver. CT of the chest revealed multiple small (<5 mm) bilateral lung nodules. Total body bone scan had no abnormal uptake. She was transferred to Methodist for further care.,The patient reports having a good appetite and denies any weight loss. She denies having any fever or chills. She has noticed increasing dyspnea with moderate exercise, but not at rest. She denies having palpitations. She occasionally has nausea, but no vomiting, constipation, or diarrhea. Over the last 2 months, she has noticed increasing facial hair and a mustache.,There is an extensive family history of colon and other cancers in her family. She was told there is a genetic defect in her family but cannot recall the name of the syndrome. She had a colonoscopy and a polyp removed at the age of 14 years old. Her last colonoscopy was 2 months ago and was unremarkable.,PAST MEDICAL HISTORY :, None.  No history of hypertension, diabetes, heart disease, liver disease or cancer.,PAST SURGICAL HISTORY:, Bilateral tubal ligation in 2001, colon polyp removed at 14 years old.,GYN HISTORY:, Gravida 2, Para 2, Ab 0. Menstrual periods have been regular, last menstrual period almost 1 month ago. No menorrhagia. Never had a mammogram. Has yearly Pap smears which have all been normal.,FAMILY HISTORY:, Mother is 61 years old and brother is 39 years old, both alive and well. Father died at 48 of colon cancer and questionable pancreatic cancer. One paternal uncle died at 32 of colon cancer and bile duct cancer. One paternal uncle had colon cancer in his 40s. Thirty cancers are noted on the father’s side of the family, many are colon; two women had breast cancer. The family was told that there is a genetic syndrome in the family, but no one remembers the name of the syndrome.,SOCIAL HISTORY:, No tobacco, alcohol or illicit drug use. Patient is born and raised in Oklahoma . No known exposures. Married with 2 children.,MEDICATION:,  None.,REVIEW OF SYSTEMS:,  No headaches. No visual, hearing, or swallowing difficulties. No cough or hemoptysis. No chest pain, PND, orthopnea. No changes in bowel or urinary habits. Otherwise, as stated in HPI.,PHYSICAL EXAM:,VS: T 97.6 BP 121/85 P 84 R 18 O2 Sat 100% on room air,GEN: Pleasant, thin woman in mild distress secondary to abdominal pain and discomfort.,HEENT: Pupils equally round and reactive to light. Extra-ocular movements intact. Anicteric. Sclerae clear. Pink conjunctiva. Moist mucous membranes. No oropharyngeal lesions.,NECK: Supple, no masses, jugular venous distention or bruits.,LUNGS: Clear to auscultation bilaterally.,HEART: Regular rate and rhythm. No murmurs, gallops, rubs.,BREASTS: Symmetric, no skin changes, no discharge, no masses,ABDOMEN: Soft with active bowel sounds. There is minimal diffuse tenderness on examination. No masses palpated. There is fullness in the right upper quadrant with negative Murphy’s sign. No rebound or guarding. The liver span is 12 cm by percussion, but not palpable below the costal margin. No splenomegaly.,PELVIC: not done,EXT: No clubbing, cyanosis, or edema. 2+ pulses bilaterally.,NEURO: Cranial nerves intact. 2+ DTRs bilaterally and symmetrically. Motor strength and sensation within the normal limits.,LYMPH: No cervical, axillary, or inguinal lymph nodes palpated,SKIN: warm, no rashes, no lesions; no tattoos,STUDIES:,CT Chest:  Multiple bilateral small (<5 mm) pulmonary nodules, no mediastinal mass or hilar adenopathy.,MRI Abdomen: 12.5 x 10.9 x 11.1 cm suprarenal mass, 7.1 x 5.4 x 6.5 cm intrahepatic lesion in the region of the dome of the liver, abnormal signal intensity within the inferior vena cava at the level of porta hepatic worrisome for thrombus.,Total Body Bone Scan: No abnormal uptake.,HOSPITAL COURSE:, ,The patient was transferred from an outside hospital for further workup and management. She was taken to the Operating Room for abdominal exploration. A liver biopsy was done.
---
DESCRIPTION: Patient presents complaining of abdominal pain and discomfort for 3 weeks.

The situation involves a 38-year-old patient with no known prior medical issues, presenting with abdominal pain that has lasted for 3 weeks, accompanied by other symptoms such as indigestion and increasing facial hair. The findings from imaging suggest the presence of significant masses in the abdominal area and possible lung involvement. The presence of a 12.5 cm suprarenal mass, a liver lesion, and multiple lung nodules raises the concern for a serious underlying condition, potentially malignant, especially given her extensive family history of cancer. These findings coupled with the genetic predisposition make the situation high-stakes as it could involve a life-threatening cancer diagnosis requiring immediate and comprehensive treatment planning.


Medical Specialty: Gastroenterology
Sample Name: Colonoscopy - 10

PREOPERATIVE DIAGNOSES: , Colon cancer screening and family history of polyps.,POSTOPERATIVE DIAGNOSIS:,  Colonic polyps.,PROCEDURE:,  Colonoscopy.,ANESTHESIA:,  MAC,DESCRIPTION OF PROCEDURE:  ,The Olympus pediatric variable colonoscope was introduced into the rectum and advanced carefully through the colon into the cecum and then through the ileocecal valve into the terminal ileum.  The preparation was excellent and all surfaces were well seen.  The mucosa was normal throughout the colon and in the terminal ileum.  Two polyps were identified and were removed.  The first was a 7-mm sessile lesion in the mid transverse colon at 110 cm, removed with the snare without cautery and retrieved.  The second was a small 4-mm sessile lesion in the sigmoid colon at 20 cm also removed with the snare and retrieved.  No other lesions were identified.  Numerous diverticula were found in the sigmoid colon.  A retroflex through the anorectal junction showed moderate internal hemorrhoids.  The patient tolerated the procedure well and was sent to the recovery room.,FINAL DIAGNOSES:,1.  Sigmoid diverticulosis.,2.  Colonic polyps in the transverse colon and sigmoid colon, benign appearance, removed.,3.  Internal hemorrhoids.,4.  Otherwise normal colonoscopy to the terminal ileum.,RECOMMENDATIONS:,1.  Follow up biopsy report.,2.  Follow up with Dr. X as needed.,3.  Screening colonoscopy in 5 years.
---
DESCRIPTION: Colon cancer screening and family history of polyps.  Sigmoid diverticulosis and internal hemorrhoids.

The situation involves a medical procedure for colon cancer screening along with the removal of colonic polyps. While the immediate procedure was completed successfully, the situation is moderately high-stakes due to the need for follow-up on the biopsy report, which could alter future medical management. Family history of polyps and cancer screening are key factors that elevate the stakes. However, no immediate complications were noted during the procedure, suggesting it was conducted safely.


Medical Specialty: General Medicine
Sample Name: Male Exam & ROS

GENERAL REVIEW OF SYSTEMS,General:  No fevers, chills, or sweats.  No weight loss or weight gain.,Cardiovascular:  No exertional chest pain, orthopnea, PND, or pedal edema.  No palpitations.,Neurologic:  No paresis, paresthesias, or syncope.,Eyes:  No double vision or blurred vision.,Ears:  No tinnitus or decreased auditory acuity.,ENT:  No allergy symptoms, such as rhinorrhea or sneezing.,GI:  No indigestion, heartburn, or diarrhea.  No blood in the stools or black stools.  No change in bowel habits.,GU:  No dysuria, hematuria, or pyuria.  No polyuria or nocturia.  Denies slow urinary stream.,Psych:  No symptoms of depression or anxiety.,Pulmonary:  No wheezing, cough, or sputum production.,Skin:  No skin lesions or nonhealing lesions.,Musculoskeletal:  No joint pain, bone pain, or back pain.  No erythema at the joints.,Endocrine:  No heat or cold intolerance.  No polydipsia.,Hematologic:  No easy bruising or easy bleeding.  No swollen lymph nodes.,PHYSICAL EXAM,Vital: Blood pressure today was *, heart rate *, respiratory rate *.,Ears:  TMs intact bilaterally.  Throat is clear without hyperemia.,Mouth:  Mucous membranes normal.  Tongue normal.,Neck:  Supple; carotids 2+ bilaterally without bruits; no lymphadenopathy or thyromegaly.,Chest:  Clear to auscultation; no dullness to percussion.,Heart:  Revealed a regular rhythm, normal S1 and S2.  No murmurs, clicks or gallops.,Abdomen:  Soft to palpation without guarding or rebound.  No masses or hepatosplenomegaly palpable.  Bowel sounds are normoactive.,Extremities:  bilaterally symmetrical.  Peripheral pulses 2+ in all extremities.  No pedal edema.,Neurologic examination:  Essentially intact including cranial nerves II through XII intact bilaterally.  Deep tendon reflexes 2+ and symmetrical.,Genitalia:  Bilaterally descended testes without tenderness or masses.  No hernias palpable.  Rectal examination revealed normal sphincter tone, no rectal mass.  Prostate was *.  Stool was Hemoccult negative.
---
DESCRIPTION: Sample male exam and review of systems.

Sample male exam and review of systems.

general medicine, male exam, cardiovascular, ent, ears, endocrine, extremities, genitalia, hemoccult, musculoskeletal, pulmonary, auditory acuity, blurred vision, heart rate, nocturia, pedal edema, percussion, polydipsia, rectal mass, regular rhythm, respiratory rate, review of systems, swollen lymph nodes, tinnitus, intact bilaterally, masses,

The situation described aligns with a routine medical examination and review of systems, which is typically low-stakes. It involves assessing a male patient's overall health status, without indicating any immediate or critical medical concerns. Given that no significant issues are reported in the examination, and the systems reviewed show no alarming symptoms, the level of urgency and risk appears to be minimal.


Medical Specialty: Surgery
Sample Name: Total Hip Replacement

PREOPERATIVE DIAGNOSIS: , Right hip osteoarthritis.,POSTOPERATIVE DIAGNOSIS: , Right hip osteoarthritis.,PROCEDURES PERFORMED: , Total hip replacement on the right side using the following components:,1.  Zimmer trilogy acetabular system 10-degree elevated rim located at the 12 o'clock position.,2.  Trabecular metal modular acetabular system 48 mm in diameter.,3.  Femoral head 32 mm diameter +0 mm neck length.,4.  Alloclassic SL offset stem uncemented for taper.,ANESTHESIA: , Spinal.,DESCRIPTION OF PROCEDURE IN DETAIL:,  The patient was brought into the operating room and was placed on the operative table in a lateral decubitus position with the right side up.  After review of allergies, antibiotics were administered and time out was performed.  The right lower extremity was prepped and draped in a sterile fashion.  A 15 cm to 25 cm in length, an incision was made over the greater trochanter.  This was angled posteriorly.  Access to the tensor fascia lata was performed.  This was incised with the use of scissors.  Gluteus maximus was separated.  The bursa around the hip was identified, and the bleeders were coagulated with the use of Bovie.  Hemostasis was achieved.  The piriformis fossa was identified, and the piriformis fossa tendon was elevated with the use of a Cobb.  It was detached from the piriformis fossa and tagged with 2-0 Vicryl.  Access to the capsule was performed.  The capsule was excised from the posterior and superior aspects.  It was released also in the front with the use of a Mayo scissors.  The hip was then dislocated.  With the use of an oscillating saw, the femoral neck cut was performed.  The acetabulum was then visualized and debrided from soft tissues and osteophytes.  Reaming was initiated and completed for a 48 mm diameter cap without complications.  The trial component was put in place and was found to be stable in an anatomic position.  The actual component was then impacted in the acetabulum.  A 10-degree lip polyethylene was also placed in the acetabular cap.  Our attention was then focused to the femur.  With the use of a cookie cutter, the femoral canal was accessed.  The broaching process was initiated for No.4 trial component.  Trialing of the hip with the hip flexed at 90 degrees and internally rotated to 30 degrees did not demonstrate any obvious instability or dislocation.  In addition, in full extension and external rotation, there was no dislocation.  The actual component was inserted in place and hemostasis was achieved again.  The wound was irrigated with normal saline.  The wound was then closed in layers.  Before performing that the medium-sized Hemovac drain was placed in the wound.  The tensor fascia lata was closed with 0 PDS and the wound was closed with 2-0 Monocryl.  Staples were used for the skin.  The patient recovered from anesthesia without complications.,EBL: , 50 mL.,IV FLUIDS: , 2 liters.,DRAINS: , One medium-sized Hemovac.,COMPLICATIONS: , None.,DISPOSITION: , The patient was transferred to the PACU in stable condition.  She will be weightbearing as tolerated to the right lower extremity with posterior hip precautions.  We will start the DVT prophylaxis after the removal of the epidural catheter.
---
DESCRIPTION: Right hip osteoarthritis.  Total hip replacement on the right side.

surgery, total hip replacement, epidural catheter, tensor fascia lata, hemostasis was achieved, medium sized hemovac, tensor fascia, fascia lata, trial component, medium sized, sized hemovac, total hip, hip replacement, hip osteoarthritis, piriformis fossa, total, hip, acetabular, extremity, tensor, fascia, hemostasis, acetabulum, dislocation, hemovac, replacement, osteoarthritis, femoral, piriformis, fossa, components, anesthesia,

The described situation is a total hip replacement surgery, which is a common and generally well-understood procedure in the medical field. While it is a major surgery and requires skill and precision, it is not considered high-stakes compared to emergency surgeries or those involving life-threatening conditions. The procedure described was completed without complications, and the patient was stable post-operatively, indicating typical surgical risk. Therefore, while it involves significant surgical intervention, it does not reach the highest levels of urgency or uncertainty.


Medical Specialty: Neurology
Sample Name: CT C-Spine

TECHNIQUE: , Sequential axial CT images were obtained through the cervical spine without contrast.  Additional high resolution coronal and sagittal reconstructed images were also obtained for better visualization of the osseous structures.  ,FINDINGS: , The cervical spine demonstrates normal alignment and mineralization with no evidence of fracture, dislocation, or spondylolisthesis.  The vertebral body heights and disc spaces are maintained.  The central canal is patent.  The pedicles and posterior elements are intact.  The paravertebral soft tissues are within normal limits.  The atlanto-dens interval and the dens are intact.  The visualized lung apices are clear.,IMPRESSION: , No acute abnormalities.
---
DESCRIPTION: Common CT C-Spine template

Common CT C-Spine template

neurology, sequential axial ct images, atlanto-dens interval, dens, ct c spine, cervical spineNOTE

The described situation involves the reading of a CT C-Spine scan, which is a routine radiological procedure to assess the cervical spine for any abnormalities. The findings indicate that everything is normal with no acute abnormalities. This is typically part of standard diagnostic practice in neurology or for trauma assessment, and the results fall within expected parameters. There are no severe implications for the patient since the scan is normal and no immediate action is required. As such, it is not a high-stakes situation.


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

CHIEF COMPLAINT: , Chronic otitis media, adenoid hypertrophy.,HISTORY OF PRESENT ILLNESS: , The patient is a 2-1/2-year-old, with a history of persistent bouts of otitis media, superimposed upon persistent middle ear effusions.  He also has a history of chronic mouth breathing and heroic snoring with examination revealing adenoid hypertrophy.  He is being admitted to the operating room at this time for adenoidectomy and bilateral myringotomy and insertion of PE tubes.,ALLERGIES:  ,None.,MEDICATIONS:,  Antibiotics p.r.n.,FAMILY HISTORY: , Diabetes, heart disease, hearing loss, allergy and cancer.,MEDICAL HISTORY: , Unremarkable.,SURGICAL HISTORY: , None.,SOCIAL HISTORY: , Some minor second-hand tobacco exposure.  There are no pets in the home.,PHYSICAL EXAMINATION:,  Ears are well retracted, immobile.  Tympanic membranes with effusions present bilaterally.  No severe congestions, thick mucoid secretions, no airflow.  Oral cavity:  Oropharynx 2 to 3+ tonsils.  No exudates.  Floor of mouth and tongue are normal.  Larynx and pharynx not examined.  Neck:  No nodes, masses or thyromegaly.  Lungs:  Reveal rare rhonchi, otherwise, clear.  Cardiac exam:  Regular rate and rhythm.  No murmurs.  Abdomen:  Soft, nontender.  Positive bowel sounds.  Neurologic exam:  Nonfocal.,IMPRESSION:  ,Chronic eustachian tube dysfunction, chronic otitis media with effusion, recurrent acute otitis media, adenoid hypertrophy.,PLAN: , The patient will be admitted to the operating room for adenoidectomy and bilateral myringotomy and insertion of PE tubes.
---
DESCRIPTION: Chronic eustachian tube dysfunction, chronic otitis media with effusion, recurrent acute otitis media, adenoid hypertrophy.

consult - history and phy., chronic eustachian tube dysfunction, chronic otitis media with effusion, recurrent acute otitis media, adenoid hypertrophy, pe tubes, otitis media with effusion, adenoidectomy and bilateral myringotomy, eustachian tube dysfunction, insertion of pe, chronic otitis media, bilateral myringotomy, otitis media, adenoidectomy, myringotomy, adenoid, hypertrophy, otitis, media,

The situation described involves a 2-1/2-year-old patient with chronic otitis media and adenoid hypertrophy, who is being admitted for surgical intervention (adenoidectomy and bilateral myringotomy with tube insertion). While the patient's condition is chronic and requires surgical treatment, such procedures are relatively common and typically have a low risk of complications, especially when performed in a controlled surgical environment. The case doesn't suggest any immediate life-threatening conditions or severe health impact if the procedure goes as planned. Hence, it is not extremely high-stakes.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Pulmonary Medicine Clinic Followup

SUBJECTIVE:,  The patient returns to the Pulmonary Medicine Clinic for followup evaluation of COPD and emphysema.  She was last seen in the clinic in March 2004.  Since that time, she has been hospitalized for psychiatric problems and now is in a nursing facility.  She is very frustrated with her living situation and would like to return to her own apartment, however, some believes she is to ill to care for herself.,At the present time, respiratory status is relatively stable.  She is still short of breath with activity, but all-in-all her pulmonary disease has not changed significantly since her last visit.  She does have occasional cough and a small amount of sputum production.  No fever or chills.  No chest pains.,CURRENT MEDICATIONS:,  The patient’s current medications are as outlined.,ALLERGIES TO MEDICATIONS:,  Erythromycin.,REVIEW OF SYSTEMS:,  Significant for problems with agitated depression.  Her respiratory status is unchanged as noted above.,EXAMINATION:,General:  The patient is in no acute distress.,Vital signs:  Blood pressure is 152/80, pulse 80 and respiratory rate 16.,HEENT:  Nasal mucosa was mild-to-moderately erythematous and edematous.  Oropharynx was clear.,Neck:  Supple without palpable lymphadenopathy.,Chest:  Chest demonstrates decreased breath sounds throughout all lung fields, coarse but relatively clear.,Cardiovascular:  Distant heart tones.  Regular rate and rhythm.,Abdomen:  Soft and nontender.,Extremities:  Without edema.,Oxygen saturation was checked today on room air, at rest it was 90%.,ASSESSMENT:,1.  Chronic obstructive pulmonary disease/emphysema, severe but stable.,2.  Mild hypoxemia, however, oxygen saturation at rest is stable without supplemental oxygen.,3.  History of depression and schizophrenia.,PLAN:,  At this point, I have recommended that she continue current respiratory medicine.  I did suggest that she would not use her oxygen when she is simply sitting, watching television or reading.  I have recommended that she use it with activity and at night.  I spoke with her about her living situation.  Encouraged her to speak with her family, as well as primary care physician about making efforts for her to return to her apartment.  Follow up evaluation is planned in Pulmonary Medicine Clinic in approximately three months or sooner if need be.
---
DESCRIPTION: Patient returns to Pulmonary Medicine Clinic for followup evaluation of COPD and emphysema.

soap / chart / progress notes, respiratory, copd, chronic obstructive pulmonary disease, pulmonary medicine clinic, depression, emphysema, followup, hypoxemia, oxygen, schizophrenia, oxygen saturation, pulmonary medicine, medicine clinic, chest, medicine, pulmonary,

The situation involves a follow-up for a patient with severe COPD and emphysema. While these conditions are serious and require ongoing management, the patient's respiratory status is noted to be stable. The patient is under regular medical supervision, including a plan for continued medication and another follow-up in three months. Although managing chronic respiratory diseases involves significant long-term care, the condition is not currently life-threatening since the patient is stable, and there is a clear management plan in place.


Medical Specialty: Consult - History and Phy.
Sample Name: Head Trauma

CC: ,Depressed mental status.,HX: ,29y/o female fell down a flight of stairs on 2/20/95, striking the right side of her head. She then walked over to and lay down on a living room couch. She was found there, the next morning, by her boyfriend, poorly responsive and amidst a coffee ground like emesis. She was taken to a local ER and HCT revealed a right supraorbital fracture, right SDH and left SAH. Spine X-rays revealed a T12 vertebral body fracture. There were retinal hemorrhages, OU. She continued to be minimally responsive and was transferred to UIHC for lack of insurance and for neurologic/neurosurgical care.,MEDS:, (on transfer): Dilantin, Zantac, Proventil MDI, Tylenol.,PMH:, 1)pyelonephritis, 2) multiple STD's, 3) Polysubstance Abuse (ETOH, MJ, Amphetamine), 4)G5P4.,FHX:, unknown.,SHX: ,polysubstance abuse. smoked 1 pack per day for 15years.,EXAM: ,BP127/97, HR83, RR25, 37.2C,MS: Minimal to no spontaneous speech. Unresponsive to verbal commands. Lethargic and somnolent. Groaned "yes" inappropriately.,CN: Pupils 4/4 decreasing to 2/2 on exposure to light. VFFTT. Retinal hemorrhages, OU. EOM difficult to assess. Facial movement appeared symmetric. Tongue midline. Corneal and gag responses were intact.,MOTOR: no spontaneous movement. withdrew extremities to noxious stimulation (e.g. deep nail bed pressure).,Sensory: withdrew to noxious stimuli.,Coord/Station/Gait: not tested.,Reflexes: 2+/2+ BUE. 2/2 BLE. Babinski signs were present, bilaterally.,HEENT: Periorbital and upper lid ecchymoses about the right eye. Scleral hemorrhage, OD.,GEN EXAM: mild bruising of the extremities.,COURSE: ,2/27/95 HCT revealed a small liner high attenuation area lateral to the right parietal lobe with subtle increased attenuation of the tentorium cerebelli. These findings were felt to represent a right subdural hematoma and possible subarachnoid hemorrhage.,2/28/95 brain MRI revealed: 1)a small right-sided SDH, 2) Abnormal signal in the right occipital lobe with effacement of the gyri and sulci in the right PCA division most likely representing ischemic/vascular injury, 3)abnormal signal within the right basal ganglia/caudate nucleus consistent with ischemia, 4) abnormal signal in the uncal portion of the right frontal lobe consistent with contusion, 5) small parenchymal hemorrhage in the inferior anterior right temporal lobe, and 6) opacification of the right maxillary sinus.,EEG, 2/28/95, was abnormal with occasional sharp transients in the left temporal region, and irregular (more or less continuous) right greater than left delta slow waves and decreased background activity in the right hemisphere: the findings were consistent with focal pathology on the right, seizure tendency in the left temporal region, and bilateral cerebral dysfunction. By the time of discharge, 4/17/95, she was verbalizing one or two words and required assistance with feeding and ambulation. She could not function independently.
---
DESCRIPTION: Closed head injury with evidence of axonal injury vs. vascular injury to the left substantia nigra, right subdural hematoma and possible subarachnoid hemorrhage, vascular/ischemic injury in the right occipital lobe-right basal ganglia/caudate nucleus-right frontal lobe, and right temporal lobe contusion.

consult - history and phy., closed head injury, axonal injury, vascular injury, substantia nigra, subdural hematoma, subarachnoid hemorrhage, vascular, ischemic, injury, occipital lobe, retinal hemorrhages, temporal region, axonal, hemorrhages, hemorrhage,

The situation involves a patient with a significant head trauma resulting in several serious neurological conditions, including subdural hematoma, subarachnoid hemorrhage, and multiple ischemic injuries in the brain. These conditions are life-threatening and can lead to long-term disability or death without urgent medical care. The patient has also shown signs of significant neural dysfunction, such as minimal responsiveness, seizures, and inability to function independently. This scenario requires immediate and highly skilled neurological and possibly surgical intervention to prevent further deterioration, making it a high-stakes medical situation.


Medical Specialty: General Medicine
Sample Name: Sleep Apnea

REASON FOR VISIT: , Mr. ABC is a 30-year-old man who returns in followup of his still moderate-to-severe sleep apnea.  He returns today to review his response to CPAP.,HISTORY OF PRESENT ILLNESS: , The patient initially presented with loud obnoxious snoring that disrupted the sleep of his bed partner.  He was found to have moderate-to-severe sleep apnea (predominantly hypopnea), was treated with nasal CPAP at 10 cm H2O nasal pressure.  He has been on CPAP now for several months, and returns for followup to review his response to treatment.,The patient reports that the CPAP has limited his snoring at night.  Occasionally, his bed partner wakes him in the middle of the night, when the mask comes off, and reminds him to replace the mask.  The patient estimates that he uses the CPAP approximately 5 to 7 nights per week, and on occasion takes it off and does not replace the mask when he awakens spontaneously in the middle of the night.,The patient's sleep pattern consists of going to bed between 11:00 and 11:30 at night and awakening between 6 to 7 a.m. on weekdays.  On weekends, he might sleep until 8 to 9 a.m.  On Saturday night, he might go to bed approximately mid night.,As noted, the patient is not snoring on CPAP.  He denies much tossing and turning and does not awaken with the sheets in disarray.  He awakens feeling relatively refreshed.,In the past few months, the patient has lost between 15 and 18 pounds in combination of dietary and exercise measures.,He continues to work at Smith Barney in downtown Baltimore.  He generally works from 8 to 8:30 a.m. until approximately 5 to 5:30 p.m.  He is involved in training purpose to how to sell managed funds and accounts.,The patient reports no change in daytime stamina.  He has no difficulty staying awake during the daytime or evening hours.,The past medical history is notable for allergic rhinitis.,MEDICATIONS: , He is maintained on Flonase and denies much in the way of nasal symptoms.,ALLERGIES: , Molds.,FINDINGS:  ,Vital signs:  Blood pressure 126/75, pulse 67, respiratory rate 16, weight 172 pounds, height 5 feet 9 inches, temperature 98.4 degrees and SaO2 is 99% on room air at rest.,The patient has adenoidal facies as noted previously.,Laboratories:  The patient forgot to bring his smart card in for downloading today.,ASSESSMENT: , Moderate-to-severe sleep apnea.  I have recommended the patient continue CPAP indefinitely.  He will be sending me his smart card for downloading to determine his CPAP usage pattern.  In addition, he will continue efforts to maintain his weight at current levels or below.  Should he succeed in reducing further, we might consider re-running a sleep study to determine whether he still requires a CPAP.,PLANS: , In the meantime, if it is also that the possible nasal obstruction is contributing to snoring and obstructive hypopnea.  I have recommended that a fiberoptic ENT exam be performed to exclude adenoidal tissue that may be contributing to obstruction.  He will be returning for routine followup in 6 months.
---
DESCRIPTION: Followup of moderate-to-severe sleep apnea.  The patient returns today to review his response to CPAP.  Recommended a fiberoptic ENT exam to exclude adenoidal tissue that may be contributing to obstruction.

general medicine, daytime stamina, fiberoptic ent exam, moderate to severe, smart card, sleep apnea, cpap, apnea, sleep,

The patient is managing a moderate-to-severe sleep apnea condition with CPAP treatment. The stakes here relate to the management of a serious, but relatively common condition that can significantly affect quality of life and has associated health risks if untreated. However, the condition is currently managed, symptoms appear to be improved, and no immediate life-threatening issues are present. The follow-up is routine, and the patient's overall health has seen positive changes, such as weight loss. The immediate risk level is low, but ongoing management is important.


Medical Specialty: Orthopedic
Sample Name: I&D & Open Reduction - Forearm

PREOPERATIVE DIAGNOSIS:  ,Grade 1 compound fracture, right mid-shaft radius and ulna with complete displacement and shortening.,POSTOPERATIVE DIAGNOSIS: , Grade 1 compound fracture, right mid-shaft radius and ulna with complete displacement and shortening.,OPERATIONS:,1.  Irrigation and debridement of skin subcutaneous tissues, muscle, and bone, right forearm.,2.  Open reduction, right both bone forearm fracture with placement of long-arm cast.,COMPLICATIONS:,  None.,TOURNIQUET: , None.,ESTIMATED BLOOD LOSS:,  25 mL.,ANESTHESIA: , General.,INDICATIONS:  ,The patient suffered injury at which time he fell over a concrete bench.  He landed mostly on the right arm.  He noted some bleeding at the time of the injury and a small puncture wound.  He was taken to the emergency room and diagnosed a compound both bone forearm fracture, and based on this, he was seen for malalignment.,He was indicated the above-noted procedure.  This procedure as well as alternatives of this procedure was discussed at length with the patient's parents and they understood them well.  Risks and benefits were also discussed.  Risks such as bleeding, infection, damage to blood vessels, damage to nerve roots, need for further surgeries, chronic pain on full range of motion, risk of continued discomfort, risk of need for repeat debridement, risk of need for internal fixation, risk of blood clots, pulmonary embolism, myocardial infarction, and risk of death were discussed.  They understood these well.  All questions were answered and they signed the consent for procedure as described.,DESCRIPTION OF PROCEDURE:  ,The patient was placed on the operating table and general anesthesia was achieved.  The right forearm was inspected.  There was noted to be a 3-mm puncture-type wound over the volar aspect of the forearm in the middle one-third overlying the radial one-half.  There was bleeding in this region.  No gross contamination was seen.  At this point, under fluoroscopic control, I did attempt to see a fracture.  I was unable to do the forearm under the close reduction techniques.  At this point, the right upper extremity was then prepped and draped in the usual sterile manner.  An incision was made through the puncture wound site extending this proximally and distally.  There was noted to be some slight amount of nonviable tissue at the skin edge and debridement was required and performed.  I also did perform a light debridement of the nonviable subcutaneous tissue, muscle, and small bony fragments were also removed.  These were all completely debrided appropriately and then at this point, a thorough irrigation was performed of the radius, which I communicated through the puncture wound.  Both ends were clearly visualized, and thorough irrigation was performed using total of 6 L of antibiotic solution.  All nonviable gross contaminated tissue was removed.  At this point with the bones in direct visualization, I did reduce the bony ends to anatomic alignment with excellent bony approximation.  Proper alignment of tissue and angulation was confirmed.,At this point, under fluoroscopic control confirmed the radius and ulna in anatomic position, which will be completely displaced and shortened previously.  The ulna was now also noted to be in anatomic alignment.,At this point, the region was thoroughly irrigated.  Hemostasis confirmed and closure then begun.  The skin was reapproximated using 3-0 nylon suture.  The visual puncture wound region was left open and this was intact with the depth of the wound down the bone using 1.5-inch Nugauze with iodoform.  Sterile dressing applied and a long-arm cast with the forearm in neutral position was applied.  X-ray with fluoroscopic evaluation was performed, which confirmed.  They maintained excellent bony approximation and the anatomic alignment.  The long-arm cast was then completely mature.  No complications were encountered throughout the procedure.  The patient tolerated the procedure well.  The patient was then taken to the recovery room in stable condition.
---
DESCRIPTION: Grade 1 compound fracture, right mid-shaft radius and ulna with complete displacement and shortening.   Irrigation and debridement of skin subcutaneous tissues, muscle, and bone, right forearm.  Open reduction, right both bone forearm fracture with placement of long-arm cast.

orthopedic, compound fracture, mid-shaft radius, ulna, open reduction, irrigation and debridement, subcutaneous, tissues, muscle, bone, forearm, radius and ulna, forearm fracture, anatomic alignment, arm cast, puncture wound, tourniquet, i&d, fracture,

The described procedure is an operation for a Grade 1 compound fracture of both the radius and ulna in the right forearm, with complete displacement and shortening. This type of surgery requires general anesthesia, careful debridement of tissue, and proper alignment of bones, which holds a magnitude of potential risks, such as infection or improper healing. Despite these risks, in the context of orthopedic surgeries, this is considered a routine procedure with manageably low complication rates. The absence of complications during surgery and the patient's stable condition postoperatively further reflects that the stakes are relatively standard for such a medical context.


Medical Specialty: Orthopedic
Sample Name: Leg Pain - Progress Note

HISTORY OF PRESENT ILLNESS: , The patient is a 44-year-old man who was seen for complaints of low back and right thigh pain.  He attributes this to an incident in which he was injured in 1994.  I do not have any paperwork authenticating his claim that there is an open claim.  Most recently he was working at Taco Bell, when he had a recurrence of back pain, and he was seen in our clinic on 04/12/05.  He rated pain of approximately 8/10 in severity., ,He took a Medrol Dosepak and states that his pain level has decreased to approximately 4-5/10.  He still localizes it to a band between L4 and the sacrum.  He initially had some right leg pain but states that this is minimal and intermittent at the present time.  His back history is significant for two laminectomies and a discectomy performed from 1990 to 1994.  The area of concern was L4-L5., ,The patient's MRI dated 10/18/04 showed multi-level degenerative changes, with facet involvement at L2-L3, L3-L4 and L5-S1.  There was no neural impingement.  He also had an MR myelogram, which showed severe stenosis at L3-L4, however it was qualified in that it may have been artifact, rather than a genuine finding., ,REVIEW OF SYSTEMS:,  Focal lower paralumbar pain, affecting both right and left sides, as well as intermittent right leg pain which appears to have improved significantly with the Medrol Dosepak.  He denies any recent illness.  He has no constitutional complaints such as fevers, chills or sweats.  HEENT: The patient denies any cephalgia, ocular, nasopharyngeal symptoms.  He has no dysphagia.  Cardiovascular: He denies any palpitations, chest pain, syncope or near-syncope.  Pulmonary: He denies any dyspnea or respiratory difficulties.  GI: The patient has no abdominal pain, nausea or vomiting.  GU: The patient denies any urinary frequency or dysuria. There is no gross hematuria.  Dermatologic: The patient notes no new onset of rash or other dermatological abnormalities.  Musculoskeletal: Denies any recent falls or near-falls.  He denies any abnormalities of endocrine, immunologic, hematologic, organ systems.  , ,MEDICATIONS: , Atenolol, Zestril, Vicodin., ,ALLERGIES:,  None., ,SOCIOECONOMIC STATUS:,  Lifting limitations of 5 pounds and limited stooping, bending and twisting., ,PHYSICAL EXAMINATION: , Vital signs:  Blood pressure 158/86, respiration 14, pulse 60, temperature 100.2.  He is sitting upright, alert and oriented and in no acute distress.  Skin is warm and dry.  Gross neurologic examination is normal.  ENT examination reveals normal oropharynx, nasopharynx, and tympanic membranes.  Neck: Full range of motion with no adenopathy or thyromegaly.  Cardiovascular: Regular rate and rhythm.  Lungs: Clear.  , ,On examination of the lumbar spine, he is minimally tender to palpation.  There is no overt muscular spasm.  His range of motion is estimated at 40 degrees of flexion and 15 degrees of extension.  Straight leg raises do not elicit any leg complaints on today's visit.  Lower extremity reflexes are symmetric., ,DIAGNOSIS: , Low back pain with a history of right leg pain.  The leg pain is no longer present.  His pain level has improved., ,PLAN:  ,1.  The patient will take another Medrol Dosepak.,2.  He can continue with physical therapy.,3.  He also continues with the same lifting restrictions.,4.  Follow up is within one week.
---
DESCRIPTION: History of right leg pain.  Leg pain is no longer present.

The situation described involves a patient experiencing low back pain with episodes of right leg pain, which has mostly resolved due to medication and physical therapy. The condition is being actively managed, with planned follow-up care. While chronic pain conditions can significantly impact quality of life, at this point, the patient's acute distress seems to be under control and there is no indication of neural impingement or other immediate complications based on recent examinations and imaging. The stakes involve managing pain effectively and ensuring no further deterioration, but it doesn't suggest life-threatening conditions. Thus, it's a moderate-stakes situation from a medical perspective focused on quality of life and long-term management rather than acute, high-risk issues.


Medical Specialty: Surgery
Sample Name: Orchiectomy

BILATERAL SCROTAL ORCHECTOMY,PROCEDURE:,:  The patient is placed in the supine position, prepped and draped in the usual manner.  Under satisfactory general anesthesia, the scrotum was approached and through a transverse mid scrotal incision, the right testicle was delivered through the incision.  Hemostasis was obtained with the Bovie and the spermatic cord was identified.  It was clamped, suture ligated with 0 chromic catgut and the cord above was infiltrated with 0.25% Marcaine for postoperative pain relief.  The left testicle was delivered through the same incision.  The spermatic cord was identified, clamped, suture ligated and that cord was also injected with 0.25% percent Marcaine.  The incision was injected with the same material and then closed in two layers using 4-0 chromic catgut continuous for the dartos and interrupted for the skin.  A dry sterile dressing fluff and scrotal support applied over that.  The patient was sent to the Recovery Room in stable condition.
---
DESCRIPTION: Bilateral scrotal orchiectomy

Bilateral scrotal orchiectomy

surgery, scrotum, hemostasis, marcaine, catgut, incision, scrotal orchiectomy, spermatic cord, sterile dressing, testicle, transverse, suture ligated, chromic catgut, orchiectomy, scrotal, cordNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.

A bilateral scrotal orchiectomy is a surgical procedure involving the removal of both testicles. This procedure is typically performed under general anesthesia and involves important considerations such as achieving proper hemostasis, preventing infection, and managing postoperative pain. Given the nature of surgical procedures, the potential for complications, and the need for effective postoperative care, this scenario involves significant stakes in terms of patient outcomes and surgical success. However, it is a fairly routine procedure for trained surgeons who specialize in urology or oncology, potentially in the context of treating testicular cancer or for hormonal management such as in advanced prostate cancer.


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: Pubic Cellulitis

DIAGNOSIS: , Pubic cellulitis.,HISTORY OF PRESENT ILLNESS:,  A 16-month-old with history of penile swelling for 4 days.  The patient was transferred for higher level of care.  This 16-month-old had circumcision 1 week ago and this is the third circumcision this patient underwent.  Apparently, the patient developed adhesions and the patient had surgery for 2 more occasions for removal of the adhesions.  This time, the patient developed fevers 3 days after the surgery with edema and erythema around the circumcision and it has spread to the pubic area.  The patient became febrile with 102 to 103 fever, treated with Tylenol with Codeine and topical antibiotics.  The patient was transferred to Children's Hospital for higher level of care.,REVIEW OF SYSTEMS: , ,ENT:  Denies any runny nose.  ,EYES:  No apparent discharge.  ,FEEDING:  Good feeding.  ,CARDIOVASCULAR:  There is no cyanosis or edema.  ,RESPIRATORY:  Denies any cough or wheezing.  ,GI:  Positive for constipation, no bowel movements for 2 days.  ,GU:  Positive dysuria for the last 2 days and penile discharge for the last 2 days with foul smelling.  ,NEUROLOGIC:  Denies any lethargy or seizure.  ,MUSCULOSKELETAL:  No pain or swelling.  ,SKIN:  Erythema and edema in the pubic area for the last 3 days.  All the rest of systems are negative except as noted above.,At the emergency room, the patient had a second dose of clindamycin.  The transfer labs are as follows:  15.7 for WBC, H&H 12.0 and 36.  One blood culture.  We will follow the results.  He is status post Rocephin and Cleocin.,PAST MEDICAL HISTORY: , Denied.  ,PAST SURGICAL HISTORY:,  The patient underwent 3 circumcisions since birth, the last 2 had been for possible removal of adhesions.,IMMUNIZATIONS: , He is behind with his immunizations.  He is due for his 16-month-old immunizations.,ACTIVITY: , NKDA.,BIRTH HISTORY: , Born to a 21-year-old, first baby, born NSVD, 8 pounds 10 ounces, no complications.,DEVELOPMENTAL:,  He is walking and speaking about 15 words.,FAMILY HISTORY: , Noncontributory.,MEDICATIONS: , Tylenol with Codeine q.6h.,SOCIAL HISTORY: , He lives with both parents and both of them smoke.  There are no pets.,SICK CONTACTS: , Mom has some upper respiratory infection.,DIET: , Regular diet.,PHYSICAL EXAMINATION: , ,VITAL SIGNS:  Temperature max at ER is 102, heart rate 153.,GENERAL:  This patient is alert, arousable, big boy.,HEENT:  Head:  Normocephalic, atraumatic.  Pupils are equal, round, and reactive to light.  Mucous membranes are moist.,NECK:  Supple.,CHEST:  Clear to auscultation bilaterally.  Good air exchange.,ABDOMEN:  Soft, nontender, nondistended.,EXTREMITIES:  Full range of movement.  No deformities.
---
DESCRIPTION: A 16-month-old with history of penile swelling for 4 days, had circumcision 1 week ago.

The case involves a 16-month-old child experiencing significant complications following multiple circumcisions. The child has developed pubic cellulitis, which can lead to serious infections if not properly managed. The child has also presented with high fever, edema, and erythema, and is receiving treatment at a children's hospital. The stakes are high primarily because this involves a young child with severe symptoms potentially indicating a systemic infection, and quick and appropriate medical intervention is crucial to prevent further complications. Additionally, any surgical complication in an infant is concerning due to their vulnerable and developing immune systems.


Medical Specialty: Consult - History and Phy.
Sample Name: Cardiac Consultation - 1

CHIEF REASON FOR CONSULTATION:,  Evaluate recurrent episodes of uncomfortable feeling in the left upper arm at rest, as well as during exertion for the last one month.,HISTORY OF PRESENT ILLNESS:,  This 57-year-old black female complains of having pain and discomfort in the left upper arm, especially when she walks and after heavy meals.  This lasts anywhere from a few hours and is not associated with shortness of breath, palpitations, dizziness, or syncope.  Patient does not get any chest pain or choking in the neck or pain in the back.  Patient denies history of hypertension, diabetes mellitus, enlarged heart, heart murmur, history suggestive of previous myocardial infarction, or acute rheumatic polyarthritis during childhood.  Her exercise tolerance is one to two blocks for shortness of breath and easy fatigability.,MEDICATIONS:,  Patient does not take any specific medications.,PAST HISTORY:,  The patient underwent hysterectomy in 1986.,FAMILY HISTORY:,  The patient is married, has four children who are doing fine.  Family history is positive for hypertension, congestive heart failure, obesity, cancer, and cerebrovascular accident.,SOCIAL HISTORY:, The patient smokes one pack of cigarettes per day and takes drinks on social occasions.
---
DESCRIPTION: To evaluate recurrent episodes of uncomfortable feeling in arm at rest, as well as during exertion.

This medical scenario describes a consultation for a patient experiencing discomfort in the left upper arm possibly related to cardiac issues. The symptoms reported include discomfort during exertion and after meals, with a noteworthy family history of hypertension and heart disease, alongside the patient's smoking habit. These factors could potentially indicate underlying cardiac conditions. Given the role of these symptoms in indicating serious health concerns such as heart disease, the situation has significant importance for diagnosing and potentially preventing serious health events, like myocardial infarction or other cardiovascular diseases.


Medical Specialty: ENT - Otolaryngology
Sample Name: Ear Laceration Repair

PREOPERATIVE DIAGNOSIS:,  Bilateral ear laceration deformities.,POSTOPERATIVE DIAGNOSIS:,  Bilateral ear laceration deformities.,PROCEDURE:,1.  Repair of left ear laceration deformity Y-V plasty 2 cm.,2.  Repair of right ear laceration deformity, complex repair 2 cm.,ANESTHESIA: , 1% Xylocaine, 1:100,000 epinephrine local.,BRIEF CLINICAL NOTE: , This patient was brought to the operating room today for the above procedure.,OPERATIVE NOTE: , The patient was laid in supine position, adequately anesthetized with the above anesthesia, sterilely prepped and draped.  The left ear laceration deformity was very close to the bottom of her ear and therefore it was transected through the centrifugal edge of the ear lobe and pared.  The marsupialized epithelialized tracts were pared to raw tissue.  They were pared in a fashion to create a Y-V plasty with de-epithelialization of the distal V and overlap of the undermined from the proximal cephalad edge.  The 5-0 chromic sutures were used to approximate anteriorly, posteriorly, and anterior centrifugal edge in the Y-V plasty fashion to decrease the risk of notching.  Bacitracin, Band-Aid was placed.  Next, attention was turned to the contralateral ear where an elongated laceration deformity was pared of the marsupialized epithelialized edges anteriorly, posteriorly to create raw edges.  This was not taken through the edge of the lobe to decrease the risk of notch deformity.  The laceration was repaired anteriorly and posteriorly in a pleated fashion to decrease length of the incision and to decrease any deformity toward the edge or any dog-ear deformity toward the edge.  The 5-0 chromic sutures were used in interrupted fashion for this.  The patient tolerated the procedure well.  Band-Aid and bacitracin were placed.  She left the operating room in stable condition.
---
DESCRIPTION: Repair of left ear laceration deformity Y-V plasty 2 cm.  Repair of right ear laceration deformity, complex repair 2 cm.

ent - otolaryngology, bilateral ear laceration, dog-ear deformity, ear laceration deformity, band aid, laceration deformity, ear laceration, laceration, deformity, ear, repair

The scenario involves a routine ENT surgical procedure to repair bilateral ear lacerations. While surgery inherently involves risks, this particular procedure appears to be straightforward and not life-threatening. The patient tolerated the procedure well and was stable post-operatively. Given the elective and reconstructive nature of the surgery, this is considered low-stakes in terms of immediate health impact.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Shortness Of Breath - Progress Note

She was evaluated this a.m. and was without any significant clinical change.  Her white count has been improving and down to 12,000.  A chest x-ray obtained today showed some bilateral infiltrates, but no acute cardiopulmonary change.  There was a suggestion of a bilateral lower lobe pneumonitis or pneumonia.,She has been on Zosyn for the infection.,Throughout her hospitalization, we have been trying to adjust her pain medications.  She states that the methadone did not work for her.  She was "immune" to oxycodone.  She had been on tramadol before and was placed back on that.  There was some question that this may have been causing some dizziness.  She also was on clonazepam and alprazolam for the underlying bipolar disorder.,Apparently, her husband was in this afternoon.  He had a box of her pain medications.  It is unclear whether she took a bunch of these or precisely what happened.  I was contacted that she was less responsive.  She periodically has some difficulty to arouse due to pain medications, which she has been requesting repeatedly, though at times does not appear to have objective signs of ongoing pain.  The nurse found her and was unable to arouse her at this point.  There was a concern that she had taken some medications from home.  She was given Narcan and appeared to come around some.  Breathing remained somewhat labored and she had some diffuse scattered rhonchi, which certainly changed from this a.m.  Additional Narcan was given as well as some medications to reverse a possible benzodiazepine toxicity.  With O2 via mask, oxygenation was stable at 90% to 95% after initial hypoxia was noted.  A chest x-ray was obtained at this time.  An ECG was obtained, which shows a sinus tachycardia, noted to have ischemic abnormalities.,In light of the acute decompensation, she was then transferred to the ICU.  We will continue the IV Zosyn.  Respiratory protocol with respiratory management.  Continue alprazolam p.r.n., but avoid if she appears sedated.  We will attempt to avoid additional pain medications, but we will continue with the Dilaudid for time being.  I suspect she will need something to control her bipolar disorder.,Pulmonary Medicine Associates have been contacted to consult in light of the ICU admission.  At this juncture, she does not appear to need an intubation.  Pending chest x-ray, she may require additional IV furosemide.
---
DESCRIPTION: The patient was admitted approximately 3 days ago with increasing shortness of breath secondary to pneumonia.  Pulmonary Medicine Associates have been contacted to consult in light of the ICU admission.

soap / chart / progress notes, shortness of breath, pulmonary medicine, bipolar disorder, icuNOTE

This situation involves a patient in a hospital setting who has experienced acute decompensation and was found less responsive, possibly due to an overdose on various medications. Due to her condition, she was transferred to the ICU for intensive monitoring and intervention. The situation is high-stakes because it involves potential life-threatening complications from a combination of respiratory issues, possible drug overdose, and the complex management of multiple medications including those for pain and bipolar disorder. The need for Narcan, possible benzodiazepine reversal, and potential for deteriorating respiratory function underscore the serious nature of her condition.


Medical Specialty: Surgery
Sample Name: Spine Fusion

PREOPERATIVE DIAGNOSIS: , Severe neurologic or neurogenic scoliosis.,POSTOPERATIVE DIAGNOSIS: , Severe neurologic or neurogenic scoliosis.,PROCEDURES:  ,1.  Anterior spine fusion from T11-L3.,2.  Posterior spine fusion from T3-L5.,3.  Posterior spine segmental instrumentation from T3-L5, placement of morcellized autograft and allograft.,ESTIMATED BLOOD LOSS: , 500 mL.,FINDINGS: , The patient was found to have a severe scoliosis.  This was found to be moderately corrected.  Hardware was found to be in good positions on AP and lateral projections using fluoroscopy.,INDICATIONS: , The patient has a history of severe neurogenic scoliosis.  He was indicated for anterior and posterior spinal fusion to allow for correction of the curvature as well as prevention of further progression.  Risks and benefits were discussed at length with the family over many visits.  They wished to proceed.,PROCEDURE:,  The patient was brought to the operating room and placed on the operating table in the supine position.  General anesthesia was induced without incident.  He was given a weight-adjusted dose of antibiotics.  Appropriate lines were then placed.  He had a neuromonitoring performed as well.,He was then initially placed in the lateral decubitus position with his left side down and right side up.  An oblique incision was then made over the flank overlying the 10th rib.  Underlying soft tissues were incised down at the skin incision.  The rib was then identified and subperiosteal dissection was performed.  The rib was then removed and used for autograft placement later.,The underlying pleura was then split longitudinally.  This allowed for entry into the pleural space.  The lung was then packed superiorly with wet lap.  The diaphragm was then identified and this was split to allow for access to the thoracolumbar spine.,Once the spine was achieved, subperiosteal dissection was performed over the visualized vertebral bodies.  This required cauterization of the segmental vessels.  Once the subperiosteal dissection was performed to the posterior and anterior extents possible, the diskectomies were performed.  These were performed from T11-L3.  This was over 5 levels.  Disks and endplates were then removed.  Once this was performed, morcellized rib autograft was placed into the spaces.  The table had been previously bent to allow for easier access of the spine.  This was then straightened to allow for compression and some correction of the curvature.,The diaphragm was then repaired as was the pleura overlying the thoracic cavity.  The ribs were held together with #1 Vicryl sutures.  Muscle layers were then repaired using a running #2-0 PDS sutures and the skin was closed using running inverted #2-0 PDS suture as well.  Skin was closed as needed with running #4-0 Monocryl.  This was dressed with Xeroform dry sterile dressings and tape.,The patient was then rotated into a prone position.  The spine was prepped and draped in a standard fashion.,Longitudinal incision was made from T2-L5.  The underlying soft tissues were incised down at the skin incision.  Electrocautery was then used to maintain hemostasis.  The spinous processes were then identified and the overlying apophyses were split.  This allowed for subperiosteal dissection over the spinous processes, lamina, facet joints, and transverse processes.  Once this was completed, the C-arm was brought in, which allowed for easy placement of screws in the lumbar spine.  These were placed at L4 and L5.  The interspaces between the spinous processes were then cleared of soft tissue and ligamentum flavum.  This was done using a rongeur as well as a Kerrison rongeur.  Spinous processes were then harvested for morcellized autograft.,Once all the interspaces were prepared, Songer wires were then passed.  These were placed from L3-T3.,Once the wires were placed, a unit rod was then positioned.  This was secured initially at the screws distally on both the left and right side.  The wires were then tightened in sequence from the superior extent to the inferior extent, first on the left-sided spine where I was operating and then on the right side spine.  This allowed for excellent correction of the scoliotic curvature.,Decortication was then performed and placement of a morcellized autograft and allograft was then performed after thoroughly irrigating the wound with 4 liters of normal saline mixed with bacitracin.  This was done using pulsed lavage.,The wound was then closed in layers.  The deep fascia was closed using running #1 PDS suture, subcutaneous tissue was closed using running inverted #2-0 PDS suture, the skin was closed using #4-0 Monocryl as needed.  The wound was then dressed with Steri-Strips, Xeroform dry sterile dressings, and tape.  The patient was awakened from anesthesia and taken to the intensive care unit in stable condition.  All instrument, sponge, and needle counts were correct at the end of the case.,The patient will be managed in the ICU and then on the floor as indicated.
---
DESCRIPTION: Anterior spine fusion from T11-L3.  Posterior spine fusion from T3-L5.  Posterior spine segmental instrumentation from T3-L5, placement of morcellized autograft and allograft.

surgery, anterior spine fusion, posterior spine fusion, spine segmental instrumentation, dry sterile dressings, autograft and allograft, pds sutures, spinous processes, spine fusion, spine, instrumentation, morcellized, allograft, fusion, autograft,

The spine fusion surgery described is a complex and invasive procedure involving both anterior and posterior approaches to correct severe neurologic scoliosis. It includes significant surgical interventions such as dissection, removal of ribs, and placement of instrumentation over a large section of the spine. The estimated blood loss is 500 mL, which is not trivial, and the procedure has been detailed carefully indicating the serious nature of the surgery. Additionally, the patient will require intensive postoperative care in the ICU, reflecting the critical nature of recovery. The surgery also involves a high level of coordination and precision, especially concerning neuromonitoring and hardware positioning, making it essential for the patient's health outcome. Therefore, this situation is high-stakes as it significantly impacts the patient's health and quality of life.


Medical Specialty: Surgery
Sample Name: Endoscopic Carpal Tunnel Rlease

PREOPERATIVE DIAGNOSIS:,  Left carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS:,  Left carpal tunnel syndrome.,OPERATIONS PERFORMED:,  Endoscopic carpal tunnel release.,ANESTHESIA:,  I.V. sedation and local (1% Lidocaine).,ESTIMATED BLOOD LOSS:,  Zero.,COMPLICATIONS:,  None.,PROCEDURE IN DETAIL: , With the patient under adequate anesthesia, the upper extremity was prepped and draped in a sterile manner.  The arm was exsanguinated.  The tourniquet was elevated at 290 mm/Hg.  Construction lines were made on the left palm to identify the ring ray.  A transverse incision was made in the wrist, between FCR and FCU, one fingerbreadth proximal to the interval between the glabrous skin of the palm and normal forearm skin.  Blunt dissection exposed the antebrachial fascia.  Hemostasis was obtained with bipolar cautery.  A distal-based window in the antebrachial fascia was then fashioned.  Care was taken to protect the underlying contents.  A proximal forearm fasciotomy was performed under direct vision.  A synovial elevator was used to palpate the undersurface of the transverse carpal ligament, and synovium was elevated off this undersurface.  Hamate sounds were then used to palpate the hook of hamate.  The endoscopic instrument was then inserted into the proximal incision.  The transverse carpal ligament was easily visualized through the portal.  Using palmar pressure, the transverse carpal ligament was held against the portal as the instrument was inserted down the transverse carpal ligament to the distal end.,The distal end of the transverse carpal ligament was then identified in the window.  The blade was then elevated, and the endoscopic instrument was withdrawn, dividing the transverse carpal ligament under direct vision.  After complete division o the transverse carpal ligament, the instrument was reinserted.  Radial and ulnar edges of the transverse carpal ligament were identified, and complete release was confirmed.,The wound was then closed with running subcuticular stitch.  Steri-Strips were applied, and sterile dressing was applied over the Steri-Strips.  The tourniquet was deflated.  The patient was awakened from anesthesia and returned to the Recovery Room in satisfactory condition, having tolerated the procedure well.
---
DESCRIPTION: Endoscopic carpal tunnel release.  Left carpal tunnel syndrome.

surgery, fcr, fcu, antebrachial fascia, endoscopic carpal tunnel release, carpal tunnel release, carpal tunnel syndrome, carpal, endoscopic, ligament, tourniquet, transverse,

The situation described is a routine surgical procedure, endoscopic carpal tunnel release, which is typically considered low to moderate risk. The details indicate that the surgery was performed without complications, with zero blood loss and under effective anesthesia. The patient's condition was stable post-procedure. While all surgeries carry inherent risks, in this specific case, the absence of complications and the successful completion of the procedure reduce the stakes significantly.


Medical Specialty: Surgery
Sample Name: PEG Tube

PREOPERATIVE DIAGNOSIS:,  Protein-calorie malnutrition.,POSTOPERATIVE DIAGNOSIS: , Protein-calorie malnutrition.,PROCEDURE PERFORMED:, Percutaneous endoscopic gastrostomy (PEG) tube.,ANESTHESIA: , Conscious sedation per Anesthesia.,SPECIMEN: , None.,COMPLICATIONS: , None.,HISTORY:  ,The patient is a 73-year-old male who was admitted to the hospital with some mentation changes.  He was unable to sustain enough caloric intake and had markedly decreased albumin stores.  After discussion with the patient and the son, they agreed to place a PEG tube for nutritional supplementation.,PROCEDURE: , After informed consent was obtained, the patient was brought to the endoscopy suite.  He was placed in the supine position and was given IV sedation by the Anesthesia Department.  An EGD was performed from above by Dr. X.  The stomach was transilluminated and an optimal position for the PEG tube was identified using the single poke method.  The skin was infiltrated with local and the needle and sheath were inserted through the abdomen into the stomach under direct visualization.  The needle was removed and a guidewire was inserted through the sheath.  The guidewire was grasped from above with a snare by the endoscopist.  It was removed completely and the Ponsky PEG tube was secured to the guidewire.,The guidewire and PEG tube were then pulled through the mouth and esophagus and snug to the abdominal wall.  There was no evidence of bleeding.  Photos were taken.  The Bolster was placed on the PEG site.  A complete dictation for the EGD will be done separately by Dr. X.  The patient tolerated the procedure well and was transferred to recovery room in stable condition.  He will be started on tube feedings in 6 hours with aspiration precautions and dietary to determine his nutritional goal.
---
DESCRIPTION: Percutaneous endoscopic gastrostomy tube.  Protein-calorie malnutrition.  The patient was unable to sustain enough caloric intake and had markedly decreased albumin stores.  After discussion with the patient and the son, they agreed to place a PEG tube for nutritional supplementation.

surgery, percutaneous endoscopic gastrostomy tube, protein calorie malnutrition, peg tube, malnutrition, nutritional

The scenario involves the placement of a PEG tube for a patient with protein-calorie malnutrition, highlighting a significant necessity due to the patient's inability to sustain sufficient caloric intake. This procedure is essential for the patient's nutrition and overall health, addressing a potentially life-threatening condition if left untreated. The execution of the procedure under conscious sedation and the absence of complications suggest it is routine but vital for the patient's recovery and health maintenance. While the PEG tube procedure itself is generally straightforward, the health implications if unaddressed are serious, making this a somewhat high-stakes situation for the patient's well-being.


Medical Specialty: Radiology
Sample Name: CT KUB

EXAM:  ,CT KUB.,REASON FOR EXAM: , Flank pain.,TECHNIQUE:,  Noncontrast CT abdomen and pelvis per renal stone protocol.,Correlation is made with the prior examination dated 01/16/09.,FINDINGS: , There is no intrarenal stone or obstruction bilaterally.  There is no hydronephrosis, ureteral dilatation.  There are calcifications about the pelvis including one in the left upper pelvis, but these are stable from the prior study and there is no upstream ureteral dilatation, the findings therefore are favored to represent phleboliths.  The bladder is nearly completely decompressed.  There is no asymmetric renal enlargement or perinephric stranding as secondary evidence of obstruction.,The appendix is normal.  There is no evidence for a pericolonic inflammatory process or small bowel obstruction.,Dedicated scan to the pelvis disclosed the aforementioned presumed phleboliths.  There is no pelvic free fluid or adenopathy.,Lung bases appear clear.  Given the lack of contrast, liver, spleen, adrenal glands, and the pancreas appear grossly unremarkable.  The gallbladder has been resected.  There is no abdominal free fluid or pathologic adenopathy.,IMPRESSION:,1. No renal stone or evidence of obstruction.  Stable appearing pelvic calcifications likely indicate phleboliths.,2. Normal appendix.
---
DESCRIPTION: Noncontrast CT abdomen and pelvis per renal stone protocol.

radiology, pericolonic inflammatory process, phleboliths, renal stone protocol, ct kub, ct abdomen, ureteral dilatation, free fluid, renal stone, noncontrast, kub, adenopathy, abdomen, ct, renal, stone, obstruction, pelvis

The CT KUB exam was conducted due to flank pain, a common symptom that could potentially indicate the presence of kidney stones or other issues in the urinary tract or abdomen. The findings showed no renal stone or obstruction, which is a positive outcome in this context, as it indicates that there are no currently significant issues requiring surgical intervention or urgent treatment. While a medical examination is always important and potentially stressful for patients, in this context, where the results did not indicate serious or life-threatening conditions, the situation is not high-stakes. The stable findings of calcifications and other structures suggest that monitoring rather than immediate action is appropriate.