Medical Specialty: Surgery
Sample Name: Nasal Septal Reconstruction

PREOPERATIVE DIAGNOSES:,1.  Chronic nasal obstruction secondary to deviated nasal septum.,2.  Inferior turbinate hypertrophy.,POSTOPERATIVE DIAGNOSES:,1.  Chronic nasal obstruction secondary to deviated nasal septum.,2.  Inferior turbinate hypertrophy.,PROCEDURE PERFORMED:,1.  Nasal septal reconstruction.,2.  Bilateral submucous resection of the inferior turbinates.,3.  Bilateral outfracture of the inferior turbinates.,ANESTHESIA:,  General endotracheal tube.,BLOOD LOSS: , Minimal less than 25 cc.,INDICATIONS: , The patient is a 51-year-old female with a history of chronic nasal obstruction.  On physical examination, she was derived to have a severely deviated septum with an S-shape deformity as well as turbinate hypertrophy present along the inferior turbinates contributing to the obstruction.,PROCEDURE:  ,After all risks, benefits, and alternatives have been discussed with the patient in detail, informed consent was obtained.  The patient was brought to the Operating Suite where she was placed in the supine position and general endotracheal intubation was delivered by the Department of Anesthesia.  The patient was rotated 90 degrees away.  Nasal pledgets saturated with 4 cc of 10% cocaine solution were inserted into the nasal cavities.  These were then removed and the nasal septum as well as the turbinates were localized with the mixture of 1% lidocaine with 1:100000 epinephrine solution.  The nasal pledgets were then reinserted as the patient was prepped in the usual fashion.  The nasal pledgets were again removed and the turbinates as well as an infraorbital nerve block was performed with 0.25% Marcaine solution.  The nasal vestibules were then cleansed with a pHisoHex solution.  A #15 blade scalpel was then used to make an incision along the length of the caudal septum.  The mucoperichondrial junction was then identified with the aid of cotton-tipped applicator as well as the stitch scissor.  Once the plane was identified, the mucosal flap on the left side of the septum was elevated with the aid of a Cottle.  At this point it should be mentioned that the patient's septum was significantly deviated with a large S-shape deformity obstructing both the right and left nasal cavity with the convex portion present in the left nasal cavity.  Again, the Cottle elevator was used to raise the mucosal flap down to the level of the septal spur.  At this point, the septal knife was used to make a crossover incision through the cartilage just anterior to the septal spur.  Again, the mucosal flap was elevated in the right nasal septum.  Now Knight scissors were used to remove the ascending portion of the nasal cartilage, which was then removed with a Takahashi forceps.  A Cottle elevator was used to further elevate the mucosal flap off the septal spur on the left side.  Removal of the spur was performed with the aid of the septal knife as well as a 3 mm straight chisel.  Once all ascending cartilage has been removed, inspection of the nasal cavity revealed patent passages with the exception of inferior turbinates that were very hypertrophied and was felt to be contributing to the patient's symptoms.  Therefore, the turbinates were again localized and a #15 blade scalpel was used to make a vertical incision dissected down to the chondral bone.  The XPS microdebrider with the inferior turbinate blade was then inserted through the incision and a submucous resection was performed by passing the microdebrider along the length of the bone.  Once the submucosal tissue had been resected, an outfracture procedure was performed so as to fully open the nasal passages.  Inspection revealed very patent and nonobstructive nasal passages.  Now the caudal incision was reapproximated with #4-0 chromic suture.  Finally, a #4-0 fast absorbing plain gut suture was used to approximate the mucosal surface of the septum in a running whipstitch fashion.  Finally, Merocel packing was placed and the patient was retuned to the Department of Anesthesia for awakening and taken to the recovery room without incident.
---
DESCRIPTION: Nasal septal reconstruction, bilateral submucous resection of the inferior turbinates, and bilateral outfracture of the inferior turbinates.  Chronic nasal obstruction secondary to deviated nasal septum and inferior turbinate hypertrophy.

surgery, chronic nasal obstruction, nasal septum, inferior turbinate hypertrophy, nasal septal reconstruction, submucous resection, inferior turbinates, outfracture, nasal septal, nasal pledgets, nasal cavity, nasal obstruction, turbinate hypertrophy, mucosal flap, septal, septum, turbinates, nasal, cavity, chronic, hypertrophy, obstruction, mucosal,

The severity of the condition being treated, chronic nasal obstruction due to a deviated septum, is moderate and commonly addressed through surgery such as nasal septal reconstruction. While surgery always involves a certain degree of risk, the procedure described includes appropriate safety measures such as anesthesia, minimal blood loss, and successful completion without incident, all of which suggest it is not extremely high-risk. However, as it's a surgical procedure under general anesthesia, it does carry more stakes compared to minor medical situations.


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

Medical Specialty: Surgery
Sample Name: Fiberoptic Flexible Bronchoscopy

PREOPERATIVE DIAGNOSES:,1.  Right hyoid mass, rule out carcinomatosis.,2.  Weight loss.,3.  Chronic obstructive pulmonary disease.,POSTOPERATIVE DIAGNOSES:,1.  Right hyoid mass, rule out carcinomatosis.,2.  Weight loss.,3.  Chronic obstructive pulmonary disease.,4.  Changes consistent with acute and chronic bronchitis.,5.  Severe mucosal irregularity with endobronchial narrowing of the right middle and lower lobes.,6.  Left vocal cord irregularity.,PROCEDURE PERFORMED:  ,Fiberoptic flexible bronchoscopy with lavage, brushings, and endobronchial mucosal biopsies of the right bronchus intermedius/right lower lobe.,ANESTHESIA: , Demerol 50 mg with Versed 3 mg as well as topical cocaine and lidocaine solution.,LOCATION OF PROCEDURE: , Endoscopy suite #4.,After informed consent was obtained and following the review of the procedure including procedure as well as possible risks and complications were explained and consent was previously obtained, the patient was sedated with the above stated medication and the patient was continuously monitored on pulse oximetry, noninvasive blood pressure, and EKG monitoring.  Prior to starting the procedure, the patient was noted to have a baseline oxygen saturation of 86% on room air.  Subsequently, she was given a bronchodilator treatment with Atrovent and albuterol and subsequent saturation increased to approximately 90% to 91% on room air.,The patient was placed on a supplemental oxygen as the patient was sedated with above-stated medication.  As this occurred, the bronchoscope was inserted into the right naris with good visualization of the nasopharynx and oropharynx.  The cords were noted to oppose bilaterally on phonation.  There was some slight mucosal irregularity noted on the vocal cord on the left side.  Additional topical lidocaine was instilled on the vocal cords, at which point the bronchoscope was introduced into the trachea, which was midline in nature.  The bronchoscope was then advanced to the distal trachea and additional lidocaine was instilled.  At this time, the bronchoscope was further advanced through the main stem and additional lidocaine was instilled.  Bronchoscope was then further advanced into the right upper lobe, which revealed no evidence of any endobronchial lesion.  The mucosa was diffusely friable throughout.  Bronchoscope was then slowly withdrawn into the right main stem and additional lidocaine was instilled.  At this point, the bronchoscope was then advanced to the right bronchus intermedius.  At this time, it was noted that there was severe mucosal irregularities of nodular in appearance significantly narrowing the right lower lobe and right middle lobe opening.  The mucosal area throughout this region was severely friable.  Additional lidocaine was instilled as well as topical epinephrine.  At this time, bronchoscope was maintained in this region and endobronchial biopsies were performed.  At the initial attempt of inserting biopsy forceps, some resistance was noted within the proximal channel at this time making advancement of the biopsy forceps out of the proximal channel impossible.  So the biopsy forceps was withdrawn and the bronchoscope was completely withdrawn and new bronchoscope was then utilized.  At this time, bronchoscope was then reinserted into the right naris and subsequently advanced to the vocal cords into the right bronchus intermedius without difficulty.  At this time, the biopsy forceps were easily passed and visualized in the right bronchus intermedius.  At this time, multiple mucosal biopsies were performed with some mild oozing noted.  Several aliquots of normal saline lavage followed.  After completion of multiple biopsies there was good hemostasis.  Cytology flushing was also performed in this region and subsequently several aliquots of additional normal saline lavage was followed.  Bronchoscope was unable to be passed distally to the base of the segment of the right lower lobe or distal to the further visualized endobronchial anatomy of the right middle lobe subsegments.  The bronchoscope was then withdrawn to the distal trachea.,At this time, bronchoscope was then advanced to the left main stem.  Additional lidocaine was instilled.  The bronchoscope was advanced to the left upper and lower lobe subsegments.  There was no endobronchial lesion visualized.  There is mild diffuse erythema and fibromucosa was noted throughout.  No endobronchial lesion was visualized in the left bronchial system.  The bronchoscope was then subsequently further withdrawn to the distal trachea and readvanced into the right bronchial system.  At this time, bronchoscope was readvanced into the right bronchus intermedius and additional aliquots of normal saline lavage until cleared.  There is no gross bleeding evidenced at this time or diffuse mucosal erythema and edema present throughout.  The bronchoscope was subsequently withdrawn and the patient was sent to recovery room.  During the bronchoscopy, the patient noted ________ have desaturation and required increasing FiO2 with subsequent increased saturation to 93% to 94%.  The patient remained at this level of saturation or greater throughout the remaining of the procedure.,The patient postprocedure relates having some intermittent hemoptysis prior to the procedure as well as moderate exertional dyspnea.  This was confirmed by her daughter and mother who were also present at the bedside postprocedure.  The patient did receive a nebulizer bronchodilator treatment immediately prebronchoscopy and postprocedure as well.  The patient also admitted to continued smoking in spite of all of the above.  The patient was extensively counseled regarding the continued smoking especially with her present symptoms.  She was advised regarding smoking cessation.  The patient was also placed on a prescription of prednisone 2 mg tablets starting at 40 mg a day decreasing every three days to continue to wean off.  The patient was also administered Solu-Medrol 60 mg IV x1 in recovery room.  There was no significant bronchospastic component noted, although because of the severity of the mucosal edema, erythema, and her complaints, short course of steroids will be instituted.  The patient was also advised to refrain from using any aspirin or other nonsteroidal anti-inflammatory medication because of her hemoptysis.  At this time, the patient was also advised that if hemoptysis were to continue or worsen or develop progressive dyspnea, to either contact myself, , or return to ABCD Emergency Room for evaluation of possible admission.  However, the above was reviewed with the patient in great detail as well as with her daughter and mother who were at the bedsite at this time as well.
---
DESCRIPTION: Fiberoptic flexible bronchoscopy with lavage, brushings, and endobronchial mucosal biopsies of the right bronchus intermedius/right lower lobe.  Right hyoid mass, rule out carcinomatosis.  Chronic obstructive pulmonary disease.  Changes consistent with acute and chronic bronchitis.

surgery, carcinomatosis, chronic obstructive pulmonary disease, fiberoptic flexible bronchoscopy, lavage, brushings, endobronchial mucosal biopsies, mucosal, bronchoscope, atrovent, topical, fiberoptic, hemoptysis, bronchoscopy, endobronchial, oropharynx

The situation involves a medical procedure on a patient with multiple serious health conditions, including COPD, potential carcinoma, and significant respiratory issues requiring immediate intervention. The bronchoscopy procedure can have significant implications for the patient's diagnosis and subsequent treatment plan. The potential for severe complications or a diagnosis of cancer increases the stakes considerably. Therefore, this scenario is high-stakes due to the critical nature of the patient's health, the complexity of the procedure, and the potential impact on the patient's overall health and treatment options.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Radiology
Sample Name: MRI Elbow - 1

FINDINGS:,There is severe tendinitis of the common extensor tendon origin with diffuse intratendinous inflammation (coronal T2 image #1452, sagittal T2 image #1672). There is irregularity of the deep surface of the tendon consistent with mild fraying (#1422 and 1484) however there is no distinct tear.,There is a joint effusion of the radiocapitellar articulation with mild fluid distention.,The radial collateral (proper) ligament remains intact. There is periligamentous inflammation of the lateral ulnar collateral ligament (coronal T2 image #1484) of the radial collateral ligamentous complex. There is no articular erosion or osteochondral defect with no intra-articular loose body.,There is minimal inflammation of the subcutis adipose space extending along the origin of the common flexor tendon (axial T2 image #1324). The common flexor tendon otherwise is normal.,There is minimal periligamentous inflammation of the anterior band of the ulnar collateral ligament (coronal T2 image #1516, axial T2 image #1452) with an intrinsically normal ligament.,The ulnotrochlear articulation is normal.,The brachialis and biceps tendons are normal with a normal triceps tendon. The anterior, posterior, medial and lateral muscular compartments are normal.,The radial, median and ulnar nerves are normal with no apparent ulnar neuritis.,IMPRESSION:,Lateral epicondylitis with severe tendinitis of the common extensor tendon origin and minimal deep surface fraying, without a discrete tendon tear.,Periligamentous inflammation of the radial collateral ligamentous complex as described above with intrinsically normal ligaments.,Small joint effusion of the radiocapitellar articulation with no osteochondral defect or intra-articular loose body.,Mild peritendinous inflammation of the subcutis adipose space adjacent to the common flexor tendon origin with an intrinsically normal tendon.,Minimal periligamentous inflammation of the anterior band of the ulnar collateral ligament with an intrinsically normal ligament.
---
DESCRIPTION: MRI Elbow - A middle-aged female complaining of elbow pain.

radiology, radial collateral ligamentous complex, intra articular loose body, axial t image, ulnar collateral ligament, common flexor tendon, mri elbow, ligamentous complex, radial collateral, ulnar collateral, collateral ligament, flexor tendon, periligamentous inflammation, mri, tendon

The case involves an MRI of the elbow showing lateral epicondylitis with severe tendinitis and related findings, but no absolute tendon tears or critical ligament issues. It appears to be a common orthopedic issue potentially impacting quality of life rather than a critical medical emergency. Management would likely focus on symptom relief and physical therapy rather than immediate surgical intervention, indicating it is not a high-stakes situation. However, radiology reports are crucial for accurate diagnosis and forming treatment plans, enhancing its importance.


Medical Specialty: Radiology
Sample Name: CT Abdomen & Pelvis - 11

EXAM: , CT pelvis with contrast and ct abdomen with and without contrast.,INDICATIONS:  ,Abnormal liver enzymes and diarrhea.,TECHNIQUE: , CT examination of the abdomen and pelvis was performed after 100 mL of intravenous contrast administration and oral contrast administration.  Pre-contrast images through the abdomen were also obtained.,COMPARISON:  ,There were no comparison studies.,FINDINGS:  ,The lung bases are clear.,The liver demonstrates mild intrahepatic biliary ductal dilatation.  These findings may be secondary to the patient's post cholecystectomy state.  The pancreas, spleen, adrenal glands, and kidneys are unremarkable.,There is a 13 mm peripheral-enhancing fluid collection in the anterior pararenal space of uncertain etiology.  There are numerous nonspecific retroperitoneal and mesenteric lymph nodes.  These may be reactive; however, an early neoplastic process would be difficult to totally exclude.,There is a right inguinal hernia containing a loop of small bowel.  This may produce a partial obstruction as there is mild fluid distention of several small bowel loops, particularly in the right lower quadrant.  The large bowel demonstrates significant diverticulosis coli of the sigmoid and distal descending colon without evidence of diverticulitis.,There is diffuse osteopenia along with significant degenerative changes in the lower lumbar spine.,The urinary bladder is unremarkable.  The uterus is not visualized.,IMPRESSION:,1.  Right inguinal hernia containing small bowel.  Partial obstruction is suspected.,2.  Nonspecific retroperitoneal and mesenteric lymph nodes.,3.  Thirteen millimeter of circumscribed fluid collection in the anterior pararenal space of uncertain etiology.,4.  Diverticulosis without evidence of diverticulitis.,5.  Status post cholecystectomy with mild intrahepatic biliary ductal dilatation.,6.  Osteopenia and degenerative changes of the spine and pelvis.
---
DESCRIPTION: Abnormal liver enzymes and diarrhea.  CT pelvis with contrast and ct abdomen with and without contrast.

radiology, pre-contrast images, contrast, biliary ductal dilatation, pancreas, spleen, adrenal glands, kidneys, mesenteric lymph nodes, fluid collection, inguinal hernia, ct abdomen, hernia, diverticulosis, diverticulitis, osteopenia, degenerative, spine, bowel, pelvis, ct, abdomen,

The findings include a right inguinal hernia that may cause partial bowel obstruction, nonspecific lymph nodes that have a differential including reactive or neoplastic causes, a fluid collection of uncertain etiology, and osteopenia with degenerative spinal changes. These findings may require further evaluation and intervention, especially the potential bowel obstruction and the fluid collection. However, they do not immediately suggest a life-threatening emergency but underscore the need for careful management and follow-up. The hernia and bowel obstruction potential require attention to prevent escalation, and the lymph nodes and fluid collection warrant further investigation for potential neoplastic processes.


Medical Specialty: General Medicine
Sample Name: Gen Med Consult - 6

SUBJECTIVE:,  The patient is in with several medical problems.  She complains of numbness, tingling, and a pain in the toes primarily of her right foot described as a moderate pain.  She initially describes it as a sharp quality pain, but is unable to characterize it more fully.  She has had it for about a year, but seems to be worsening.  She has little bit of paraesthesias in the left toe as well and seem to involve all the toes of the right foot.  They are not worse with walking.  It seems to be worse when she is in bed.  There is some radiation of the pain up her leg.  She also continues to have bilateral shoulder pains without sinus allergies.  She has hypothyroidism.  She has thrombocythemia, insomnia, and hypertension.,PAST MEDICAL HISTORY:,  Surgeries include appendectomy in 1933, bladder obstruction surgery in 1946, gallbladder surgery in 1949, another gallbladder surgery in 1954, C-section in 1951, varicose vein surgery in 1951 and again in 1991, thyroid gland surgery in 1964, hernia surgery in 1967, bilateral mastectomies in 1968 for benign disease, hysterectomy leaving her ovaries behind in 1970, right shoulder surgery x 4 and left shoulder surgery x 2 between 1976 and 1991, and laparoscopic bowel adhesion removal in October 2002.  She had a Port-A-Cath placed in June 2003, left total knee arthroplasty in June 2003, and left hip pinning due to fracture in October 2003, with pins removed in May 2004.  She has had a number of colonoscopies; next one is being scheduled at the end of this month.  She also had a right total knee arthroplasty in 1993.  She was hospitalized for synovitis of the left knee in April 2004, for zoster and infection of the left knee in May 2003, and for labyrinthitis in June 2004.,ALLERGIES: , Sulfa, aspirin, Darvon, codeine, NSAID, amoxicillin, and quinine.,CURRENT MEDICATIONS:,  Hydroxyurea 500 mg daily, Metamucil three teaspoons daily, amitriptyline 50 mg at h.s., Synthroid 0.1 mg daily, Ambien 5 mg at h.s., triamterene/hydrochlorothiazide 75/50 daily, and Lortab 5/500 at h.s. p.r.n.,SOCIAL HISTORY:,  She is a nonsmoker and nondrinker.  She has been widowed for 18 years.  She lives alone at home.  She is retired from running a restaurant.,FAMILY HISTORY:,  Mother died at age 79 of a stroke.  Father died at age 91 of old age.  Her brother had prostate cancer.  She has one brother living.  No family history of heart disease or diabetes.,REVIEW OF SYSTEMS:,General:  Negative.,HEENT:  She does complain of some allergies, sneezing, and sore throat.  She wears glasses.,Pulmonary history:  She has bit of a cough with her allergies.,Cardiovascular history:  Negative for chest pain or palpitations.  She does have hypertension.,GI history:  Negative for abdominal pain or blood in the stool.,GU history:  Negative for dysuria or frequency.  She empties okay.,Neurologic history:  Positive for paresthesias to the toes of both feet, worse on the right.,Musculoskeletal history:  Positive for shoulder pain.,Psychiatric history:  Positive for insomnia.,Dermatologic history:  Positive for a spot on her right cheek, which she was afraid was a precancerous condition.,Metabolic history:  She has hypothyroidism.,Hematologic history:  Positive for essential thrombocythemia and anemia.,OBJECTIVE:,General:  She is a well-developed, well-nourished, elderly female in no acute distress.,Vital Signs:  Her age is 81.  Temperature:  98.0.  Blood pressure:  140/70.  Pulse:  72.  Weight:  127.,HEENT:  Head was normocephalic.  Pupils equal, round, and reactive to light.  Extraocular movements are intact.  Fundi are benign.  TMs, nares, and throat were clear.,Neck:  Supple without adenopathy or thyromegaly.,Lungs:  Clear.,Heart:  Regular rate and rhythm without murmur, click, or rub.  No carotid bruits are heard.,Abdomen:  Normal bowel sounds.  It is soft and nontender without hepatosplenomegaly or mass.,Breasts:  Surgically absent.  No chest wall mass was noted, except for the Port-A-Cath in the left chest.  No axillary adenopathy is noted.,Extremities:  Examination of the extremities reveals no ankle edema or calf tenderness x 2 in lower extremities.  There is a cyst on the anterior portion of the right ankle.  Pedal pulses were present.,Neurologic:  Cranial nerves II-XII grossly intact and symmetric.  Deep tendon reflexes were 1 to 2+ bilaterally at the knees.  No focal neurologic deficits were observed.,Pelvic:  BUS and external genitalia were atrophic.  Vaginal rugae were atrophic.  Cervix was surgically absent.  Bimanual exam confirmed the absence of uterus and cervix and I could not palpate any ovaries.,Rectal:  Exam confirmed there is brown stool present in the rectal vault.,Skin:  Clear other than actinic keratosis on the right cheek.,Psychiatric:  Affect is normal.,ASSESSMENT:,1.  Peripheral neuropathy primarily of the right foot.,2.  Hypertension.,3.  Hypothyroidism.,4.  Essential thrombocythemia.,5.  Allergic rhinitis.,6.  Insomnia.,PLAN:
---
DESCRIPTION: Patient with several medical problems - numbness, tingling, and a pain in the toes.

The situation involves an elderly patient with multiple medical conditions, including peripheral neuropathy, hypertension, hypothyroidism, essential thrombocythemia, and insomnia. The patient's symptoms have worsened over a year, potentially indicating a serious underlying condition that could affect her quality of life. However, she is in no acute distress, and the situation is being managed as a consult rather than an emergency, indicating that it's not immediately life-threatening. Nonetheless, given her age and medical history, careful management is essential.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Gen Med SOAP - 2

SUBJECTIVE:,  Overall, she has been doing well.  Her blood sugars have usually been less than or equal to 135 by home glucose monitoring.  Her fasting blood sugar today is 120 by our Accu-Chek.  She is exercising three times per week.  Review of systems is otherwise unremarkable. ,OBJECTIVE:,  Her blood pressure is 110/60.  Other vitals are stable.  HEENT:  Unremarkable.  Neck:  Unremarkable.  Lungs:  Clear.  Heart:  Regular.  Abdomen:  Unchanged.  Extremities:  Unchanged.  Neurologic:  Unchanged. ,ASSESSMENT:,  ,1.  NIDDM with improved control. ,2.  Hypertension. ,3.  Coronary artery disease status post coronary artery bypass graft. ,4.  Degenerative arthritis. ,5.  Hyperlipidemia. ,6.  Hyperuricemia. ,7.  Renal azotemia. ,8.  Anemia. ,9.  Fibroglandular breasts. ,PLAN:,  We will get follow-up labs today.  We will continue with current medications and treatment.  We will arrange for a follow-up mammogram as recommended by the radiologist in six months, which will be approximately Month DD, YYYY.  The patient is advised to proceed with previous recommendations.  She is to follow-up with Ophthalmology and Podiatry for diabetic evaluation and to return for follow-up as directed.
---
DESCRIPTION: Patient with NIDDM, hypertension, CAD status post CABG, hyperlipidemia, etc.

soap / chart / progress notes, general medicine, accu-chek, heent: unremarkable, hyperlipidemia, hypertension, lungs: clear, niddm, neck: unremarkable, progress note, soap, coronary artery bypass graft, follow-up labs, glucose monitoring, coronary artery

The case describes a routine follow-up for a patient with multiple chronic conditions like non-insulin dependent diabetes mellitus (NIDDM), hypertension, hyperlipidemia, and coronary artery disease. While these conditions are serious, the patient appears stable, and the plan includes standard follow-up labs and continuation of current treatments. The case does not involve immediate risk or emergency intervention, reducing the stakes involved.


Medical Specialty: Orthopedic
Sample Name: Anterior Cervical Discectomy & Arthrodesis - 1

PREOPERATIVE DIAGNOSES: , C5-C6 disc herniation with right arm radiculopathy.,POSTOPERATIVE DIAGNOSES: , C5-C6 disc herniation with right arm radiculopathy.,PROCEDURE:,1.  C5-C6 arthrodesis, anterior interbody technique.,2.  C5-C6 anterior cervical discectomy.,3.  C5-C6 anterior instrumentation with a 23-mm Mystique plate and the 13-mm screws.,4.  Implantation of machine bone implant.,5.  Microsurgical technique.,ANESTHESIA:  ,General endotracheal.,ESTIMATED BLOOD LOSS: , Less than 100 mL.,BACKGROUND INFORMATION AND SURGICAL INDICATIONS:  ,The patient is a 45-year-old right-handed gentleman who presented with neck and right arm radicular pain.  The pain has become more and more severe.  It runs to the thumb and index finger of the right hand and it is accompanied by numbness.  If he tilts his neck backwards, the pain shoots down the arm.  If he is working with the computer, it is very difficult to use his mouse.  He tried conservative measures and failed to respond, so he sought out surgery.  Surgery was discussed with him in detail.  A C5-C6 anterior cervical discectomy and fusion was recommended.  He understood and wished to proceed with surgery.  Thus, he was brought in same day for surgery on 07/03/2007.,DESCRIPTION OF PROCEDURE: , He was given Ancef 1 g intravenously for infection prophylaxis and then transported to the OR.  There general endotracheal anesthesia was induced.  He was positioned on the OR table with an IV bag between the scapulae.  The neck was slightly extended and taped into position.  A metal arch was placed across the neck and intraoperative x-ray was obtain to verify a good position for skin incision and the neck was prepped with Betadine and draped in the usual sterile fashion.,A linear incision was created in the neck beginning just to the right of the midline extending out across the anterior border of the sternocleidomastoid muscle.  The incision was extended through skin, subcutaneous fat, and platysma.  Hemostasis was assured with Bovie cautery.  The anterior aspect of the sternocleidomastoid muscle was identified and dissection was carried medial to this down to the carotid sheath.  The trachea and the esophagus were swept out of the way and dissection proceeded medial to the carotid sheath down between the two bellies of the longus colli muscle on to the anterior aspect of the spine.  A Bovie cautery was used to mobilize the longus colli muscle around initially what turned out to be C6-C7 disk based on x-rays and then around the C5-C6 disk space.  An intraoperative x-ray confirmed C5-C6 disk space had been localized and then the self-retained distraction system was inserted to maintain exposure.  A 15-blade knife was used to incise the C5-C6 disk and remove disk material. and distraction pins were inserted into C5-C6 and distraction placed across the disk space.  The operating microscope was then brought into the field and used throughout the case except for the closure.  Various pituitaries, #15 blade knife, and curette were used to evacuate the disk as best as possible.  Then, the Midas Rex drill was taken under the microscope and used to drill where the cartilaginous endplate driven back all the way into the posterior aspect of the vertebral body.  A nerve hook was swept underneath the posterior longitudinal ligament and a fragment of disk was produced and was pulled up through the ligament.  A Kerrison rongeur was used to open up the ligament in this opening and then to march out in the both neural foramina.  A small amount of disk material was found at the right neural foramen.  After a good decompression of both neural foramina was obtained and the thecal sac was exposed throughout the width of the exposure, the wound was thoroughly irrigated.  A spacing mechanism was intact into the disk space and it was determined that a #7 spacer was appropriate.  So, a #7 machine bone implant was taken and tapped into disk space and slightly counter sunk.  The wound was thoroughly irrigated and inspected for hemostasis.  A Mystique plate 23 mm in length was then inserted and anchored to the anterior aspect of C5-C6 to hold the bone into position and the wound was once again irrigated.  The patient was valsalved.  There was no further bleeding seen and intraoperative x-ray confirmed a good position near the bone, plate, and screws and the wound was enclosed in layers.  The 3-0 Vicryl was used to approximate platysma and 3-0 Vicryl was used in inverted interrupted fashion to perform a subcuticular closure of the skin.  The wound was cleaned.,Mastisol was placed on the skin, and Steri-strips were used to approximate skin margins.  Sterile dressing was placed on the patient's neck.  He was extubated in the OR and transported to the recovery room in stable condition.  There were no complications.
---
DESCRIPTION: Arthrodesis - anterior interbody technique, anterior cervical discectomy, anterior instrumentation with a 23-mm Mystique plate and the 13-mm screws, implantation of machine bone implant.  Disc herniation with right arm radiculopathy.

orthopedic, herniation, radiculopathy, interbody, mystique, bone implant, anterior cervical discectomy, neural foramina, mystique plate, disc herniation, arm radiculopathy, cervical discectomy, disk space, disk, cervical, anterior, wound, discectomy,

The procedure described is a common orthopedic surgery involving discectomy and arthrodesis to relieve radiculopathy caused by a herniated disc. While such surgeries carry inherent risks (e.g., infection, bleeding, nerve damage, etc.), they are routine and usually conducted by experienced surgeons. This particular case indicates a successful surgery with no complications, minimal blood loss, and stable post-operative condition, factors that suggest a well-managed, low-risk operation. However, as with any surgery, especially involving the spine, there are always certain risks that need to be managed attentively.


Medical Specialty: Autopsy
Sample Name: Autopsy - 6

ANATOMICAL SUMMARY,1. Sharp force wound of neck, left side, with transection of left internal jugular vein.,2. Multiple stab wounds of chest, abdomen, and left thigh: Penetrating stab wounds of chest and abdomen with right hemothorax and hemoperitoneum.,3. Multiple incised wounds of scalp, face, neck, chest and left hand (defense wound).,4. Multiple abrasions upper extremities and hands (defense wounds).,NOTES AND PROCEDURES,1. The body is described in the Standard Anatomical Position. Reference is to this position only.,2. Where necessary, injuries are numbered for reference. This is arbitrary and does not correspond to any order in which they may have been incurred. All the injuries are antemortem, unless otherwise specified.,3. The term "anatomic" is used as a specification to indicate correspondence with the description as set forth in the textbooks of Gross Anatomy. It denotes freedom from significant, visible or morbid alteration.,EXTERNAL EXAMINATION:, The body is that of a well developed, well nourished Caucasian male stated to be 25 years old. The body weighs 171 pounds, measuring 69 inches from crown to sole. The hair on the scalp is brown and straight. The irides appear hazel with the pupils fixed and dilated.  The sclerae and conjunctive are unremarkable, with no evidence of petechial hemorrhages on either. Both upper and lower teeth are natural, and there are no injuries of the gums, cheeks, or lips.,There is a picture-type tattoo on the lateral aspect of the left upper arm. There are no deformities, old surgical scars or amputations.,Rigor mortis is fixed.,The body appears to the Examiner as stated above. Identification is by toe tag and  the autopsy is not material to identification. The body is not embalmed.,The head is normocephalic, and there is extensive evidence of external traumatic injury, to be described below. Otherwise, the eyes, nose and mouth are not remarkable. The neck shows sharp force injuries to be described below. The front of the chest and abdomen likewise show injuries to be described below. The genitalia are that of an adult male, with the penis circumcised, and no evidence of injury.,Examination of the posterior surface of the trunk reveals no antemortem traumatic injuries.,Refer to available photographs and diagrams and to the specific documentation of the autopsy protocol.,CLOTHING:,  The clothes were examined both before and after removal from the body.,The decedent was wearing a long-sleeved type of shirt/sweater; it was extensively bloodstained.,On the front, lower right side, there was a 1 1/2 inch long slit-like tear. Also on the lower right sleeve there was a 1 inch slit-like tear. On the back there was a 1/2 inch slit-like tear on the right lower side.,Decedent was wearing a pair of Levi jeans bloodstained.  On the outside of the left hip region there was a 1-1/2 inch long slit-like tear. The decedent also was wearing 2 canvas type boots and 2 sweat socks.,EVIDENCE OF THERAPEUTIC INTERVENTION:,  None.,EVIDENCE OF INJURY,SHARP FORCE INJURIES OF NECK,1.  Sharp force injury of neck, left side, transecting left internal jugular vein. This sharp force injury is complex, and appears to be a combination of a stabbing and cutting wound. It begins on the left side of the neck, at the level of the midlarynx, over the left sternocleidomastoid muscle; it is gaping, measuring 3 inches in length with smooth edges. It tapers superiorly to 1 inch in length cut skin. Dissection discloses that the wound path is through the skin, the subcutaneous tissue, and the sternocleidomastoid muscle with hemorrhage along the wound path and transection of the left internal jugular vein, with dark red-purple hemorrhage in the adjacent subcutaneous tissue and fascia. The direction of the pathway is upward and slightly front to back for a distance of approximately 4 inches where it exits, post-auricular, in a 2 inch in length gaping stab/incised wound which has undulating or wavy borders, but not serrated. Intersecting the wound at right angle superior inferior is a 2 inch in length interrupted superficial, linear incised wound involving only the skin. Also, intervening between the 2 gaping stab-incised wounds is a horizontally oriented 3-1/2 inch in length interrupted superficial, linear incised wound of the skin only.  In addition, there is a 1/2 inch long, linear-triangular in size wound of the inferior portion of the left earlobe.  The direction of the sharp force injury is upward (rostral), and slightly front to back with no significant angulation or deviation. The total length of the wound path is approximately 4 inches. However, there is a 3/4 inch in length, linear, cutting or incised wound of the top or superior aspect of the pinna of the left ear; a straight metallic probe placed through the major sharp force injury shows that the injury of the superior part of the ear can be aligned with the straight metallic rod, suggesting that the 3 injuries are related; in this instance the total length of the wound path is approximately 6 inches. Also, in the left postauricular region, transversely oriented, extending from the auricular attachment laterally to the scalp is a 1-1/8 inch in length linear superficial incised skin wound.,OPINION: , This sharp force injury of the neck is fatal, associated with transection of the left internal jugular vein.,2.  Sharp force wound of the right side of neck. This is a complex injury, appearing to be a combination stabbing and cutting wound. The initial wound is present on the right side of the neck, over the sternocleidomastoid muscle, 3 inches directly below the right external auditory canal. It is diagonally oriented, and after approximation of the edges measures 5/8 inch in length; there is a pointed or tapered end inferiorly and a split or forked end superiorly approximately 1/16 inch in maximal width. Subsequent autopsy shows that the wound path is through the skin and subcutaneous tissue, without penetration of injury of a major,artery or vein; the direction is front to back and upward for a total wound path length of 2 inches and the wound exits on the right side of the back of the neck, posterior to the right sternocleidomastoid muscle where a 2 inch long gaping incised/stab wound is evident on the skin; both ends are tapered; superiorly there is a 1 inch long superficial incised wounds extension on the skin to the back of the head; inferiorly there is a 2 inch long incised superficial skin extension, extending inferiorly towards the back of the neck. There is fresh hemorrhage and bruising along the wound path; the direction, as stated, is upward and slightly front to back.,OPINION: ,This is a nonfatal sharp force injury, with no injury or major artery or vein.,3.  At the level of the superior border of the larynx there is a transversely oriented, superficial incised wound of the neck, extending from 3 inches to the left of the anterior midline; it is 3 inches in length and involves the skin only; a small amount of cutaneous hemorrhage is evident.,OPINION:, This is a nonfatal superficial incised wound.,4.  ImmediateLY inferior and adjacent to incised wound #3 is a transversely oriented, superficial incised wound involving the skin and subcutaneous tissue; there is a small amount of dermal hemorrhage.,OPINION:, This is a nonfatal superficial incised wound.,SHARP FORCE INJURIES OF FACE,1.  There is a stab wound, involving the right earlobe; it is vertically oriented, and after approximation of the edges measures 1 inch in length with forked or split ends superiorly and inferiorly approximately 1/16 inch in total width both superior and inferior. Subsequent dissection discloses that the wound path is from right to left, in the horizontal plane for approximately 1-1/4 inches; there is fresh hemorrhage along the wound path; the wound path terminates in the left temporal bone and does not penetrate the cranial cavity.,OPINION:, This is a nonfatal stab wound.,2.  There is a group of 5 superficial incised or cutting wounds on the right side of the face, involving the right cheek and the right side of the jaw. They are varied in orientation both diagonal and horizontal; the smallest is 1/4 inch in length; the largest 5/8 inch in length. They are superficial, involving the skin only, associated with a small amount of cutaneous hemorrhage.,3.  On the back of the neck, right side, posterior to the ear and posterior border of the right sternocleidomastoid muscle there is vertically oriented superficial incised skin wound, measuring 3/4 inch in length.,4.  There are numerous superficial incised wounds or cuts, varied in orientation, involving the skin of the right cheek, intersection and mingled with the various superficial incised wounds described above. The longest is a 3 inch long diagonally oriented superficial incised wound extending from the right side of the forehead to the cheek; various other superficial wound vary from 1/2 to 1 inch.,5.  On the right side of the cheek, adjacent to the ramus of the mandible, right, there is a 1-1/2 x 3/4 inch superficial nonpatterned red-brown abrasion with irregular border, extending superiorly towards the angle of the jaw where there are poorly defined and circumscribed abrasions adjacent to the superficial cuts or abrasions described above. It should be noted that the 5th superficial incised wound of the right side of the mandible which measures 5/8 inch in length is tapered on the posterior aspect and forked on the anterior aspect where it has a width of 1/32 inch.,6.  On the left ear, there is a superficial incised wound measuring 1/4 inch, adjacent to the posterior border of the pinna. Just below this on the inferior pinna, extending to the earlobe, there is an interrupted superficial linear abrasion measuring 1 inch in length.
---
DESCRIPTION: Multiple sharp force injuries, involving chest and abdomen, multiple incised-stab wounds of the neck, and multiple incised or cutting wounds.

The given situation involves the analysis of a detailed autopsy report of an individual who suffered multiple fatal and non-fatal sharp force injuries. Autopsies are typically conducted in cases of unnatural deaths, often related to criminal investigations or suspicious circumstances. The high-stakes nature of this situation is due to its implications for legal proceedings, the determination of cause and manner of death, and potential impacts on justice for the involved parties. The meticulous documentation and findings in an autopsy play a crucial role in investigations, making this a high-stakes scenario.


Medical Specialty: Discharge Summary
Sample Name: Discharge Summary

DISCHARGE DIAGNOSES:,1.  Acute respiratory failure, resolved.,2.  Severe bronchitis leading to acute respiratory failure, improving.,3.  Acute on chronic renal failure, improved.,4.  Severe hypertension, improved.,5.  Diastolic dysfunction.,X-ray on discharge did not show any congestion and pro-BNP is normal.,SECONDARY DIAGNOSES:,1.  Hyperlipidemia.,2.  Recent evaluation and treatment, including cardiac catheterization, which did not show any coronary artery disease.,3.  Remote history of carcinoma of the breast.,4.  Remote history of right nephrectomy.,5.  Allergic rhinitis.,HOSPITAL COURSE:, This 83-year-old patient had some cold symptoms, was treated as bronchitis with antibiotics.  Not long after the patient returned from Mexico, the patient started having progressive shortness of breath, came to the emergency room with severe bilateral wheezing and crepitations.  X-rays however did not show any congestion or infiltrates and pro-BNP was within normal limits.  The patient however was hypoxic and required 4L nasal cannula.  She was admitted to the Intensive Care Unit.  The patient improved remarkably over the night on IV steroids and empirical IV Lasix.  Initial swab was positive for MRSA colonization., ,Discussed with infectious disease, Dr. X and it was decided no treatment was required for de-colonization.  The patient's breathing has improved.  There is no wheezing or crepitations and O2 saturation is 91% on room air.  The patient is yet to go for exercise oximetry.  Her main complaint is nasal congestion and she is now on steroid nasal spray.  The patient was seen by Cardiology, Dr. Z, who advised continuation of beta blockers for diastolic dysfunction.  The patient has been weaned off IV steroids and is currently on oral steroids, which she will be on for seven days.,DISPOSITION: , The patient has been discharged home.,DISCHARGE MEDICATIONS:,1.  Metoprolol 25 mg p.o. b.i.d.,2.  Simvastatin 20 mg p.o. daily.,NEW MEDICATIONS:,1.  Prednisone 20 mg p.o. daily for seven days.,2.  Flonase nasal spray daily for 30 days.,Results for oximetry pending to evaluate the patient for need for home oxygen.,FOLLOW UP:,  The patient will follow up with Pulmonology, Dr. Y in one week's time and with cardiologist, Dr. X in two to three weeks' time.
---
DESCRIPTION: Patient had some cold symptoms, was treated as bronchitis with antibiotics.

discharge summary, acute respiratory failure, bronchitis, acute on chronic renal failure, severe hypertension, diastolic dysfunction, cold symptoms, iv steroids, nasal spray, nasal, steroids,

The discharge summary details a significant medical event involving acute respiratory failure, among other conditions, that required intensive care treatment. While not immediately life-threatening upon discharge, the situation involves a complex patient history that needs careful management and follow-up. The stakes involve ensuring successful recovery and preventing readmission due to potential complications from multiple conditions, including diastolic dysfunction and recent acute respiratory distress.


Medical Specialty: Discharge Summary
Sample Name: Discharge Summary - Multiple Trauma

ADMITTING DIAGNOSIS:,  Aftercare of multiple trauma from an motor vehicle accident.,DISCHARGE DIAGNOSES:,1.  Aftercare following surgery for injury and trauma.,2.  Decubitus ulcer, lower back.,3.  Alcohol induced persisting dementia.,4.  Anemia.,5.  Hypokalemia.,6.  Aftercare healing traumatic fracture of the lower arm.,7.  Alcohol abuse, not otherwise specified.,8.  Aftercare healing traumatic lower leg fracture.,9.  Open wound of the scalp.,10.  Cervical disk displacement with myelopathy.,11.  Episodic mood disorder.,12.  Anxiety disorder.,13.  Nervousness.,14.  Psychosis.,15.  Generalized pain.,16.  Insomnia.,17.  Pain in joint pelvic region/thigh.,18.  Motor vehicle traffic accident, not otherwise specified.,PRINCIPAL PROCEDURES:,  None.,HISTORY OF PRESENT ILLNESS: , As per Dr. X without any changes or corrections.,HOSPITAL COURSE:  ,This is a 50-year-old male, who is initially transferred from Medical Center after treatment for multiple fractures after a motor vehicle accident.  He had a left tibial plateau fracture, right forearm fracture with ORIF, head laceration, and initially some symptoms of head injury.  When he was initially transferred to HealthSouth, he was status post ORIF for his right forearm.  He had a brace placed in the left leg for his left tibial plateau fracture.  He was confused initially and initially started on rehab.  He was diagnosed with some acute psychosis and thought problems likely related to his alcohol abuse history.  He did well from orthopedic standpoint.  He did have a small sacral decubitus ulcer, which was well controlled with the wound care team and healed quite nicely.  He did have some anemia initially and he had dropped down in to the low 9, but he was 9.2 with his lowest on 06/11/2008, which had responded well to iron treatment and by the time of discharge, he was lower at 11.0.  He made slow progress from therapy.  His confusion gradually cleared.  He did have some problems with insomnia and was placed on Seroquel to help with both of his moods and other issues and he did quite well with this.  He did require some Ativan for agitation.  He was on chronic pain medications as an outpatient.  His medications were adjusted here and he did well with this as well.  The patient was followed throughout his entire stay with case management and discussions were made with them and the psychologist concerning the placement upon discharge to an acute alcohol rehab facility; however, the patient refused throughout this entire stay.  We did have orthopedic followup.  He was taken out of his right leg brace the week of 06/16/2008.  He did well with therapy.  Overall, he was doing much and much better.  He had progressed with the therapy to the point where that he was comfortable to go home and receive outpatient therapy and follow up with his primary care physician.  On 06/20/2008, with all parties in agreement, the patient was discharged to home in stable condition.,At the time of discharge, the patient's ambulatory status was much better.  He was using a wheeled walker.  He was able to bear weight on his left leg.  His pain level had been well controlled and his moods had improved dramatically.  He was no longer having any signs of agitation or confusion and he seemed to be at a stable baseline.  His anemia had resolved almost completely and he was doing quite well. ,MEDICATIONS: , On discharge included:,1.  Calcium with vitamin D 1 tablet twice a day.,2.  Ferrous sulfate 325 mg t.i.d.,3.  Multivitamin 1 daily.,4.  He was on nicotine patch 21 mg per 24 hour.,5.  He was on Seroquel 25 mg at bedtime.,6.  He was on Xenaderm for his sacral pressure ulcer.,7.  He was on Vicodin p.r.n. for pain.,8.  Ativan 1 mg b.i.d. for anxiety and otherwise he is doing quite well.,The patient was told to follow up with his orthopedist Dr. Y and also with his primary care physician upon discharge.
---
DESCRIPTION: Aftercare of multiple trauma from an motor vehicle accident.

This discharge summary describes a complex medical case involving multiple traumas from a motor vehicle accident, compounded by issues like alcohol-induced dementia, an ulcer, and psychiatric conditions. While the patient was stable at discharge, there is still a need for continued outpatient care, and potential for future complications if any of these conditions are not carefully managed. However, since the patient is stable and receiving outpatient care, the immediate stakes are not as high as they could be, but the complexity of health issues does elevate the stakes somewhat.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Podiatry - Progress Note

SUBJECTIVE:,  Mr. Sample Patient returns to the Sample Clinic with the chief complaint of painful right heel.  The patient states that the heel has been painful for approximately two weeks, it is starts with the first step in the morning and gets worse with activity during the day.  The patient states that he is currently doing no treatment for it.  He states that most of his pain is along medial tubercle of the right calcaneus and extends to the medial arch.  The patient states that he has no change in the past medical history since his last visit and denies any fever, chills, vomiting, headache, chest, or shortness of breath.,OBJECTIVE:,  Upon removal of shoes and socks bilaterally, neurovascular status remains unchanged since the last visit.  There is tenderness to palpation to the medial tubercle of the right foot.  The pain is elicited along the medial arch as well.  There are no open areas or signs of infection noted.,ASSESSMENT:,  Plantar fascitis/heel spur syndrome, right foot.,PLAN:,  The patient was given injections of 3 cc 2:1 mixture of 1% lidocaine plain with dexamethasone phospate.  He was given a low dye strapping and a heel lift was placed in his right shoe.  The patient will be seen back in approximately one month for further evaluation if necessary.  He was told to call if anything should occur before that.  The patient was told to continue with the good work on his diabetic control.
---
DESCRIPTION: Plantar fascitis/heel spur syndrome.  The patient was given injections of 3 cc 2:1 mixture of 1% lidocaine plain with dexamethasone phospate.

soap / chart / progress notes, progress note, plantar fascitis, podiatry, soap, dexamethasone phospate, heel lift, heel spur syndrome, lidocaine, low dye strapping, mixture of 1% lidocaine, dexamethasone, phospate, injections, heel

The scenario involves a patient's visit to the clinic for a painful right heel. While the pain seems to impact the patient's daily life and could potentially affect mobility, the condition described is plantar fasciitis/heel spur syndrome, which is a common and treatable issue. The treatment plan is straightforward and includes a follow-up. There's no indication of severe risk to the patient's immediate health or life. This situation is low-stakes in terms of urgency or critical health deterioration.


Medical Specialty: Psychiatry / Psychology
Sample Name: Psychiatric Discharge Summary - 1

DISCHARGE SUMMARY,SUMMARY OF TREATMENT PLANNING:,Two major problems were identified at the admission of this adolescent:,1.
---
DESCRIPTION: Discharge summary of a patient with mood swings and oppositional and defiant behavior.

The discharge summary of a psychiatric patient involves understanding the treatment undergone, the patient's response, and planning future care. The stakes are moderate to high because providing accurate summaries can influence follow-up care and impact patient recovery. However, since this is a summary and not an ongoing treatment decision, it is not the highest stakes possible.


Medical Specialty: Orthopedic
Sample Name: Hemiarthroplasty - Shoulder

PREOPERATIVE DIAGNOSIS:,  Comminuted fracture, dislocation left proximal humerus.,POSTOPERATIVE DIAGNOSIS:, Comminuted fracture, dislocation left proximal humerus.,PROCEDURE PERFORMED: , Hemiarthroplasty of left shoulder utilizing a global advantage system with an #8 mm cemented humeral stem and 48 x 21 mm modular head replacement.,PROCEDURE:  ,The patient was taken to OR #2, administered general anesthetic.  He was positioned in the modified beach chair position on the operative table utilizing the shoulder apparatus.  The left shoulder and upper extremities were then prepped and draped in the usual manner.  A longitudinal incision was made extending from a point just lateral to the coracoid down towards deltoid tuberosity of the humerus.  This incision was taken down through the skin and subcutaneous tissues were split utilizing the coag cautery.  Hemostasis was achieved with the cautery.  The deltoid fascia were identified, skin flaps were then created.  The deltopectoral interval was identified and the deltoid split just lateral to the cephalic vein.  The deltoid was then retracted.  There was marked hematoma and swelling within the subdeltoid bursa.  This area was removed with rongeurs.  The biceps tendon was identified which was the landmark for the rotator interval.  Mayo scissors was utilized to split the remaining portion of the rotator interval.  The greater tuberosity portion with the rotator cuff was identified.  Excess bone was removed from the greater tuberosity side to allow for closure later.  The lesser tuberosity portion with the subscapularis was still attached to the humeral head, therefore, osteotome was utilized to separate the lesser tuberosity from the humeral head fragment.,Excess bone was removed from the lesser tuberosity as well.  Both of these were tagged with Ethibond sutures for later.  The humeral head was delivered out of the wound.  It was localized to the area of the anteroinferior glenoid region.  The glenoid was then inspected, and noted to be intact.  The fracture was at the level of the surgical neck on the proximal humerus.  The canal was repaired with the broaches.  An #8 stem was chosen as it was going to be cemented into place.  The trial stem was impacted into position and the shaft of the bone marked with the cautery to the appropriate retroversion.  Trial reduction was performed.  The 48 x 21 mm head was the most appropriate size, matching the patient's as well as the soft tissue tension on the shoulder.  At this point, the wound was copiously irrigated with gentamycin solution.  The canal was copiously irrigated as well and suctioned dry.  Methyl methacrylate cement was mixed.  The cement gun was filled and the canal was filled with the cement.  The #8 stem was then impacted into place and held in the position in the appropriate retroversion until the cement had cured.  Excess cement was removed by sharp dissection.  Prior to cementation of the stem, a hole was drilled in the shaft of proximal humerus and #2 fiber wires were placed through this hole for closure later.  Once the cement was cured, the modular head was impacted on to the Morse taper.  It was stable and the shoulder was reduced.  The lesser tuberosity was then reapproximated back to the original site utilizing the #2 fiber wire suture that was placed in the humeral shaft as well as the holes in the humeral implant.  The greater tuberosity portion with rotator cuff was also attached to the implant as well as the shaft of the humerus utilizing #2 fiber wires as well.  The rotator interval was closed with #2 fiber wire in an interrupted fashion.  The biceps tendon was ________ within this closure.  The wound was copiously irrigated with gentamycin solution, suctioned dry.  The deltoid fascia was then approximated with interrupted #2-0 Vicryl suture.  Subcutaneous layer was approximated with interrupted #2-0 Vicryl and skin approximated with staples.  Subcutaneous tissues were infiltrated with 0.25% Marcaine solution.  A bulky dressing was applied to the wound followed by application of a large arm sling.  Circulatory status was intact in the extremity at the completion of the case.  The patient was then transferred to recovery room in apparent satisfactory condition.
---
DESCRIPTION: Hemiarthroplasty of left shoulder utilizing a global advantage system with an #8 mm cemented humeral stem and 48 x 21 mm modular head replacement.  Comminuted fracture, dislocation left proximal humerus.

orthopedic, dislocation, proximal humerus, comminuted fracture, rotator interval, tuberosity portion, hemiarthroplasty, fracture, wound, proximal, deltoid, rotator, stem, humeral, humerus, tuberosity, cemented,

The described situation is a surgical procedure involving a hemiarthroplasty of the shoulder due to a comminuted fracture and dislocation of the left proximal humerus. Such procedures are significant as they involve general anesthesia, surgical intervention, and have potential risks associated with the surgery and recovery, including infection, complications from anesthesia, and the need for rehabilitation. However, it does not represent an immediate life-threatening emergency akin to cardiac surgery or brain surgery. Therefore, while important and complex, it is not considered extremely high-stakes by medical standards.


Medical Specialty: Gastroenterology
Sample Name: CT Abdomen & Pelvis - 10

CT ABDOMEN WITHOUT CONTRAST AND CT PELVIS WITHOUT CONTRAST,REASON FOR EXAM: , Evaluate for retroperitoneal hematoma, the patient has been following, is currently on Coumadin.,CT ABDOMEN: , There is no evidence for a retroperitoneal hematoma.,The liver, spleen, adrenal glands, and pancreas are unremarkable.  Within the superior pole of the left kidney, there is a 3.9 cm cystic lesion.  A 3.3 cm cystic lesion is also seen within the inferior pole of the left kidney.  No calcifications are noted.  The kidneys are small bilaterally.,CT PELVIS: , Evaluation of the bladder is limited due to the presence of a Foley catheter, the bladder is nondistended.  The large and small bowels are normal in course and caliber.  There is no obstruction.,Bibasilar pleural effusions are noted.,IMPRESSION:,1. No evidence for retroperitoneal bleed.,2. There are two left-sided cystic lesions within the kidney, correlation with a postcontrast study versus further characterization with an ultrasound is advised as the cystic lesions appear slightly larger as compared to the prior exam.,3. The kidneys are small in size bilaterally.,4. Bibasilar pleural effusions.
---
DESCRIPTION: Evaluate for retroperitoneal hematoma, the patient has been following, is currently on Coumadin.  CT abdomen without contrast and CT pelvis without contrast.

gastroenterology, cystic lesion, superior pole, kidney, ct pelvis, ct abdomen, retroperitoneal hematoma, lesion, kidneys, bladder, bibasilar, pleural, effusions, lesions, pelvis, hematoma, retroperitoneal, cystic, ct, abdomen,

The situation described involves a medical examination using CT scans to evaluate a critical condition, specifically checking for a retroperitoneal hematoma in a patient who is on Coumadin, a blood thinner. While the report finds no hematoma, it identifies other potential issues, such as kidney cysts and pleural effusions, that may require further investigation. Being on Coumadin increases the risks associated with any bleeds or new findings, which can complicate treatment. Hence, it is somewhat high-stakes due to the potential seriousness of the underlying conditions and the medication involved.


Medical Specialty: Neurology
Sample Name: Rotator Cuff Tear

REASON FOR VISIT: , Followup left-sided rotator cuff tear and cervical spinal stenosis.,HISTORY OF PRESENT ILLNESS: , Ms. ABC returns today for followup regarding her left shoulder pain and left upper extremity C6 radiculopathy.  I had last seen her on 06/21/07.,At that time, she had been referred to me Dr. X and Dr. Y for evaluation of her left-sided C6 radiculopathy.  She also had a significant rotator cuff tear and is currently being evaluated for left-sided rotator cuff repair surgery, I believe on, approximately 07/20/07.  At our last visit, I only had a report of her prior cervical spine MRI.  I did not have any recent images.  I referred her for cervical spine MRI and she returns today.,She states that her symptoms are unchanged.  She continues to have significant left-sided shoulder pain for which she is being evaluated and is scheduled for surgery with Dr. Y.,She also has a second component of pain, which radiates down the left arm in a C6 distribution to the level of the wrist.  She has some associated minimal weakness described in detail in our prior office note.  No significant right upper extremity symptoms.  No bowel, bladder dysfunction.  No difficulty with ambulation.,FINDINGS: , On examination, she has 4 plus over 5 strength in the left biceps and triceps muscle groups, 4 out of 5 left deltoid, 5 out of 5 otherwise in both muscle groups and all muscle groups of upper extremities.  Light touch sensation is minimally decreased in the left C6 distribution; otherwise, intact.  Biceps and brachioradialis reflexes are 1 plus.  Hoffmann sign normal bilaterally.  Motor strength is 5 out of 5 in all muscle groups in lower extremities.  Hawkins and Neer impingement signs are positive at the left shoulder.,An EMG study performed on 06/08/07 demonstrates no evidence of radiculopathy or plexopathy or nerve entrapment to the left upper extremity.,Cervical spine MRI dated 06/28/07 is reviewed.  It is relatively limited study due to artifact.  He does demonstrate evidence of minimal-to-moderate stenosis at the C5-C6 level but without evidence of cord impingement or cord signal change.  There appears to be left paracentral disc herniation at the C5-C6 level, although axial T2-weighted images are quite limited.,ASSESSMENT AND PLAN: , Ms. ABC's history, physical examination and radiographic findings are compatible with left shoulder pain and left upper extremity pain, which is due to a combination of left-sided rotator cuff tear and moderate cervical spinal stenosis.,I agree with the plan to go ahead and continue with rotator cuff surgery.  With regard to the radiculopathy, I believe this can be treated non-operatively to begin with.  I am referring her for consideration of cervical epidural steroid injections.  The improvement in her pain may help her recover better from the shoulder surgery.,I will see her back in followup in 3 months, at which time she will be recovering from a shoulder surgery and we will see if she needs any further intervention with regard to the cervical spine.,I will also be in touch with Dr. Y to let him know this information prior to the surgery in several weeks.
---
DESCRIPTION: Followup left-sided rotator cuff tear and cervical spinal stenosis.  Physical examination and radiographic findings are compatible with left shoulder pain and left upper extremity pain, which is due to a combination of left-sided rotator cuff tear and moderate cervical spinal stenosis.

neurology, upper extremity, radiculopathy, rotator cuff repair, cervical spinal stenosis, rotator cuff tear, physical examination, cuff, impingement, stenosis, extremity, surgery, tear, shoulder, rotator, cervical,

The situation involves ongoing management of a rotator cuff tear and cervical spinal stenosis. While shoulder surgery is planned, the cervical condition is being managed non-operatively initially. Although surgery and spinal concerns are not trivial, the case is handled with a routine follow-up and non-urgent recommendations. The absence of life-threatening symptoms like bowel, bladder dysfunction, or cord impingement further suggests it's a non-critical case.


Medical Specialty: Surgery
Sample Name: Laparoscopic Ablation of Eendometrial Implants

PREOPERATIVE DIAGNOSES:,1.  Pelvic pain.,2.  Hypermenorrhea.,POSTOPERATIVE DIAGNOSES:,1.  Pelvic pain.,2.  Hypermenorrhea.,3.  Mild pelvic endometriosis.,PROCEDURE PERFORMED:,1.  Dilatation and curettage (D&C).,2.  Laparoscopic ablation of endometrial implants.,ANESTHESIA:  ,General endotracheal.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Less than 50 cc.,SPECIMEN: , Endometrial curettings.,INDICATIONS: , This is a 26-year-old female with a history of approximately one year of heavy painful menses.  She did complain of some dyspareunia and wants a definitive diagnosis.,FINDINGS: , On bimanual exam, the uterus is small and anteverted with mildly decreased mobility on the left side.  There are no adnexal masses appreciated.  On laparoscopic exam, the uterus is normal appearing but slightly compressible.  The bilateral tubes and ovaries appear normal.  There is evidence of endometriosis on the left pelvic sidewall in the posterior cul-de-sac.  There was no endometriosis in the right pelvic sidewall or along the bladder flap.,There were some adhesions on the right abdominal sidewall from the previous appendectomy.  The liver margin, gallbladder, and bowel appeared normal.  The uterus was sounded to 9 cm.,PROCEDURE: , After consent was obtained, the patient was taken to the operating room and general anesthetic was administered.  The patient was placed in dorsal lithotomy position and prepped and draped in normal sterile fashion.  Sterile speculum was placed in the patient's vagina.  The anterior lip of the cervix was grasped with vulsellum tenaculum.  The uterus was sounded to 9 cm.  The cervix was then serially dilated with Hank dilators.  A sharp curettage was performed until a gritty texture was noted in all aspects of the endometrium.  The moderate amount of tissue that was obtained was sent to Pathology.  The #20 Hank dilator was then replaced and the sterile speculum was removed.  Gloves were changed and attention was then turned to the abdomen where approximately 10 mm transverse infraumbilical incision was made.  The Veress needle was placed into this incision and the gas was turned on.  When good flow and low abdominal pressures were noted, the gas was turned up and the abdomen was allowed to insufflate.  The #11 mm trocar was then placed through this incision and a camera was placed with the above findings noted.  A Bierman needle was placed 2 cm superior to the pubic bone and along the midline to allow a better visualization of the pelvic organs.  A 5 mm port was placed approximately 7 cm to 8 cm to the right of the umbilicus and approximately 3 cm inferior.  The harmonic scalpel was placed through this port and the areas of endometriosis were ablated using the harmonic scalpel.  A syringe was placed on to the Bierman needle and a small amount of fluid in the posterior cul-de-sac was removed to allow better visualization of the posterior cul-de-sac.  The lesions in the posterior cul-de-sac were then ablated using the Harmonic scalpel.  All instruments were then removed.  The Bierman needle and 5 mm port was removed under direct visualization with excellent hemostasis noted.  The camera was removed and the abdomen was allowed to desufflate.  The 11 mm trocar introducer was replaced and the trocar was removed.  The skin was closed with #4-0 undyed Vicryl in subcuticular fashion.  ,Approximately 10 cc of 0.25% Marcaine was placed in the incision sites.  The dilator and vulsellum tenaculum were removed from the patient's cervix with excellent hemostasis noted.  The patient tolerated the procedure well.  Sponge, lap, and needle counts were correct at the end of procedure.  The patient was taken to the recovery room in satisfactory condition.  She will be discharged home with a prescription for Darvocet for pain and is instructed to follow up in the office in two weeks with further treatment will be discussed including approximately six months of continuous monophasic oral contraceptives.
---
DESCRIPTION: Dilatation and curettage (D&C) and Laparoscopic ablation of endometrial implants.  Pelvic pain, hypermenorrhea, and mild pelvic endometriosis.

surgery, pelvic pain, hypermenorrhea, endometriosis, dilatation and curettage, d&c, endometrial implants, ablation, cul de sac, vulsellum tenaculum, hank dilators, laparoscopic ablation, bierman needle, pelvic,

The situation involves a surgical procedure, which inherently carries risks such as infection, bleeding, or adverse reactions to anesthesia. However, this specific procedure was completed without complications, the estimated blood loss was minimal, and the patient tolerated the procedure well. The surgery addresses a significant quality of life issue for the patient (pelvic pain and hypermenorrhea due to endometriosis), but it does not appear immediately life-threatening. The postoperative plan is for outpatient care and a routine follow-up. Considering these factors, while the surgery is a critical intervention for the patient's quality of life, it is not extremely high-stakes in terms of life-endangering potential.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Bronchoscopy & Foreign Body Removal

PREOPERATIVE DIAGNOSIS: , Foreign body in airway.,POSTOPERATIVE DIAGNOSIS:,  Plastic piece foreign body in the right main stem bronchus.,PROCEDURE: , Rigid bronchoscopy with foreign body removal.,INDICATIONS FOR PROCEDURE: , This patient is 7-month-old baby boy who presented to emergency room today with increasing stridor and shortness of breath according to mom.  The patient had a chest x-ray and based on that there is concern by the Radiology it could be a foreign body in the right main stem.  The patient has been taken to the operating room for rigid bronchoscopy and foreign body removal.,DESCRIPTION OF PROCEDURE:  ,The patient was taken to the operating room, placed supine, put under general mask anesthesia.  Using a 3.5 rigid bronchoscope we visualized between the cords into the trachea.  There were some secretions but that looked okay.  Got down at the level of the carina to see a foreign body flapping in the right main stem.  I then used graspers to grasp to try to pull into the scope itself.  I could not do that, I thus had to pull the scope out along with the foreign body that was held on to with a grasper.  It appeared to be consisting of some type of plastic piece that had broke off some different object.  I took the scope and put it back down into the airway again.  Again, there was secretion in the trachea that we suctioned out.  We looked down into the right bronchus intermedius.  There was no other pathology noted, just some irritation in the right main stem area.  I looked down the left main stem as well and that looked okay as well.  I then withdrew the scope.  Trachea looked fine as well as the cords.  I put the patient back on mask oxygen to wake the patient up.  The patient tolerated the procedure well.
---
DESCRIPTION: Plastic piece foreign body in the right main stem bronchus.  Rigid bronchoscopy with foreign body removal.

cardiovascular / pulmonary, main stem bronchus, bronchoscopy, airway, foreign body removal, rigid bronchoscopy,

The situation involves a 7-month-old baby with a foreign object obstructing their airway, which is a life-threatening situation. The child presented with increasing stridor and shortness of breath, indicating significant respiratory distress. Timely removal of the foreign object through rigid bronchoscopy was crucial to prevent further respiratory compromise or potentially fatal outcomes. The high-stakes nature of the situation lies in the acute risk to the child's airway and the need for immediate intervention to secure breathing and prevent asphyxiation.


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

Medical Specialty: Pediatrics - Neonatal
Sample Name: Congestion & Cough - 5-month-Old

CHIEF COMPLAINT: , Congestion and cough.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 5-month-old infant who presented initially on Monday with a cold, cough, and runny nose for 2 days.  Mom states she had no fever.  Her appetite was good but she was spitting up a lot.  She had no difficulty breathing and her cough was described as dry and hacky.  At that time, physical exam showed a right TM, which was red.  Left TM was okay.  She was fairly congested but looked happy and playful.  She was started on Amoxil and Aldex and we told to recheck in 2 weeks to recheck her ear.  Mom returned to clinic again today because she got much worse overnight.  She was having difficulty breathing.  She was much more congested and her appetite had decreased significantly today.  She also spiked a temperature yesterday of 102.6 and always having trouble sleeping secondary to congestion.,ALLERGIES: , She has no known drug allergies.,MEDICATIONS:  ,None except the Amoxil and Aldex started on Monday.,PAST MEDICAL HISTORY:  ,Negative.,SOCIAL HISTORY: , She lives with mom, sister, and her grandparent.,BIRTH HISTORY: , She was born, normal spontaneous vaginal delivery at Woman's weighing 7 pounds 3 ounces.  No complications.  Prevented, she passed her hearing screen at birth.,IMMUNIZATIONS: , Also up-to-date.,PAST SURGICAL HISTORY: , Negative.,FAMILY HISTORY:  ,Noncontributory.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Her respiratory rate was approximately 60 to 65.,GENERAL:  She was very congested and she looked miserable.  She had no retractions at this time.,HEENT:  Her right TM was still red and irritated with no light reflex.  Her nasal discharge was thick and whitish yellow.  Her throat was clear.  Her extraocular muscles were intact.,NECK:  Supple.  Full range of motion.,CARDIOVASCULAR EXAM:  She was tachycardic without murmur.,LUNGS:  Revealed diffuse expiratory wheezing.,ABDOMEN:  Soft, nontender, and nondistended.,EXTREMITIES:  Showed no clubbing, cyanosis or edema.,LABORATORY DATA:  ,Her chem panel was normal.  RSV screen is positive.  Chest x-ray and CBC are currently pending.,IMPRESSION AND PLAN:  ,RSV bronchiolitis with otitis media.  Admit for oral Orapred, IV Rocephin, nebulizer treatments and oxygen as needed.
---
DESCRIPTION: A 5-month-old infant with cold, cough, and runny nose for 2 days.  Mom states she had no fever.  Her appetite was good but she was spitting up a lot.

The situation involves a 5-month-old infant with respiratory syncytial virus (RSV) bronchiolitis and otitis media, which has worsened significantly, leading to difficulty breathing, a high fever, and decreased appetite. Infants, especially those under six months, are vulnerable to complications from RSV, such as severe respiratory distress and lethargy. The infant's respiratory rate is high, and the presence of wheezing and congestion can indicate compromised airways, necessitating close monitoring and possible hospitalization. Immediate intervention with medications such as Orapred, Rocephin, nebulizer treatments, and oxygen is planned. Given the age of the patient and the potential for rapid deterioration in such cases, this situation is considered high-stakes.


Medical Specialty: Surgery
Sample Name: ORIF - Talus

PREOPERATIVE DIAGNOSIS:, Hawkins IV talus fracture.,POSTOPERATIVE DIAGNOSIS: , Hawkins IV talus fracture.,PROCEDURE PERFORMED:,1.  Open reduction internal fixation of the talus.,2.  Medial malleolus osteotomy.,3.  Repair of deltoid ligament.,ANESTHESIA: , Spinal.,TOURNIQUET TIME: , 90 min.,BLOOD LOSS:,  50 cc.,The patient is in the semilateral position on the beanbag.,INTRAOPERATIVE FINDINGS:,  A comminuted Hawkins IV talus fracture with an incomplete rupture of the deltoid ligament.  There was no evidence of osteochondral defects of the talar dome.,HISTORY:  ,This is a 50-year-old male who presented to ABCD General Hospital Emergency Department with complaints of left ankle pain and disfigurement.  There was no open injury.  The patient fell approximately 10 feet off his liner, landing on his left foot.  There was evidence of gross deformity of the ankle.  An x-ray was performed in the Emergency Room, which revealed a grade IV Hawkins classification talus fracture.  He was distal neurovascularly intact.  The patient denied any other complaints besides pain in the ankle.,It was for this reason, we elected to undergo the above-named procedure in order to reduce and restore the blood supply to the talus body.  Because of its tenuous blood supply, the patient is at risk for avascular necrosis.  The patient has agreed to undergo the above-named procedure and consent was obtained.  All risks as well as complications were discussed.,PROCEDURE: , The patient was brought back to operative room #4 of ABCD General Hospital on 08/20/03.  A spinal anesthetic was administered.  A nonsterile tourniquet was placed on the left upper thigh, but not inflated.  He was then positioned on the beanbag.  The extremity was then prepped and draped in the usual sterile fashion for this procedure.  An Esmarch was then used to exsanguinate the extremity and the tourniquet was then inflated to 325 mmHg.  At this time, an anteromedial incision was made in order to perform a medial malleolus osteotomy to best localize the fracture region in order to be able to bone graft the comminuted fracture site.  At this time, a #15 blade was used to make approximately 10 cm incision over the medial malleolus.  This was curved anteromedial along the root of the saphenous vein.  The saphenous vein was located.  Its tributaries going plantar were cauterized and the vein was retracted anterolaterally.  At this time, we identified the medial malleolus.  There was evidence of approximately 80% avulsion, rupture of the deltoid ligament off of the medial malleolus.  This was a major blood feeder to the medial malleolus and we were concerned, once we were going to do the osteotomy, that this would later create healing problem.  It is for this reason that the pedicle, which was attached to the medial malleolus, was left intact.  This pedicle was the anterior portion of the deltoid ligament.  At this time, a MicroChoice saw was then used to make a box osteotomy of the medial malleolus.  Once this was performed, the medial malleolus was retracted anterolaterally with its remaining pedicle intact for later blood supply.  This provided us with excellent exposure to the fracture site of the medial side.  At this time, any loose comminuted pieces were removed.  The dome of the talus was also checked and did not reveal any osteochondral defects.  There was some comminution on the dorsal aspect of the complete talus fracture and we were concerned that once we place the screw, this would tend to extend the fracture site.  It is for this reason, we did the medial malleolar osteotomy to prevent this from happening in order to best expose the fracture site.  At this time, a reduction was performed.  The #7-0 partially threaded cannulated screws were used in order to fix the fracture.  At this time, a 3.2 mm guidewire was placed going from posterolateral to anteromedial.,This was placed slightly lateral to the Achilles tendon, percutaneously inserted, and then drilled in the according fashion across the fracture site.  Once this was performed, a skin knife was then used to incise over the percutaneous insertion in order to accommodate the screw going in.  A depth gauze was then used to measure screw length.  A cannulated drill was then used to drill across the fracture site to allow the entrance of the screw.  A 55 mm partially threaded #7-0 cannulated screw was then placed with excellent compression at the fracture site.  Once this was obtained, we checked the reduction again using intraoperative Xi-Scan in the AP and lateral direction.  This projection gave us excellent view of our screw placement and excellent compression across the fracture site.  At this time, we bone grafted the area of comminution using 1 cc of DynaGraft with crushed cancellous allograft.  This was placed using a freer elevator into the fracture site where the comminution was.  At this time, we copiously irrigated the wound.  The osteotomy site was then repaired, first clamped using two large tenaculum reduction clamps.  Two partially threaded #4-0 cannulated screws were then used to fix the osteotomy site and anatomical reduction was performed with excellent compression across the osteotomy site with the two screws.  Next, a #1-0 Vicryl was then used to repair the deltoid ligament, which was ruptured via the injury.  A tight repair was performed of the deltoid ligament.  At this time, again copious irrigation was used to irrigate the wound.  A #2-0 Vicryl was then used to approximate the subcutaneous skin and staples for the skin incision.  At this time, the leg was cleansed, Adaptic, 4 x 4, and Kerlix roll were then applied.  The patient was then placed in a plaster splint for mobilization.  The tourniquet was then released.  The patient was then transferred off the operating table to recovery in stable condition.  The prognosis for this fracture is guarded.  There is a high rate of avascular necrosis of the talar body, approximately anywhere from 40-60% risk.  The patient is aware of this and he will be followed as an outpatient for this problem.
---
DESCRIPTION: Hawkins IV talus fracture.  Open reduction internal fixation of the talus, medial malleolus osteotomy, and repair of deltoid ligament.

surgery, deltoid ligament, medial malleolus osteotomy, open reduction internal fixation of the talus, hawkins iv talus fracture, medial malleolus, fracture site, malleolus, talus, medial, fracture, tourniquet, ligament, osteotomy,

The scenario involves a surgical procedure to address a complex Hawkins IV talus fracture with associated risks such as avascular necrosis, which can lead to serious complications if not managed properly. This type of fracture is known for its complexity and the high stakes associated with ensuring proper blood supply to prevent further damage to the talus. The procedure requires careful planning and execution to minimize risks and ensure the best possible outcome for the patient. Therefore, the stakes are high due to the potential for significant long-term implications on the patient's mobility and health.


Medical Specialty: ENT - Otolaryngology
Sample Name: Consult - Jaw Pain

HISTORY:  ,The patient is a 53-year-old male who was seen for evaluation at the request of Dr. X regarding recurrent jaw pain.  This patient has been having what he described as numbness and tingling along the jaw, teeth, and tongue.  This numbness has been present for approximately two months.  It seems to be there "all the time."  He was seen by his dentist and after dental evaluation was noted to be "okay."  He had been diagnosed with a throat infection about a week ago and is finishing a course of Avelox at this time.  He has been taking cough drops and trying to increase his fluids.  He has recently stopped tobacco.  He has been chewing tobacco for about 30 years.  Again, there is concern regarding the numbness he has been having.  He has had a loss of sensation of taste as well.  Numbness seems to be limited just to the left lateral tongue and the jaw region and extends from the angle of the jaw to the lip.  He does report he has had about a 20-pound of weight gain over the winter, but notes he has had this in the past just simply from decreased activity.  He has had no trauma to the face.  He does note a history of headaches.  These are occasional and he gets these within the neck area when they do flare up.  The headaches are noted to be less than one or two times per month.  The patient does note he has a history of anxiety disorder as well.  He has tried to eliminate his amount of tobacco and he is actually taking Nicorette gum at this time.  He denies any fever or chills.  He is not having any dental pain with biting down.  He has had no jaw popping and no trismus noted.  The patient is concerned regarding this numbness and presents today for further workup, evaluation, and treatment.,REVIEW OF SYSTEMS: , Other than those listed above were otherwise negative.,PAST SURGICAL HISTORY: , Pertinent for hernia repair.,FAMILY HISTORY: , Pertinent for hypertension.,CURRENT MEDICATIONS:,  Tylenol.  He is on Nicorette gum.,ALLERGIES:  ,He is allergic to codeine, unknown reaction.,SOCIAL HISTORY:  ,The patient is single, self-employed carpenter.  He chews tobacco or having chewing tobacco for 30 years, about half a can per day, but notes he has been recently off, and he does note occasional moderate alcohol use.,PHYSICAL EXAMINATION: , ,VITAL SIGNS:  Blood pressure is 138/82, pulse 64 and regular, temperature 98.3, and weight is 191 pounds.,GENERAL:  The patient is an alert, cooperative, obese, 53-year-old male with a normal-sounding voice and good memory.,HEAD & FACE:  Inspected with no scars, lesions or masses noted.  Sinuses palpated and are normal.  Salivary glands also palpated and are normal with no masses noted.  The patient also has full facial function.,CARDIOVASCULAR:  Heart regular rate and rhythm without murmur.,RESPIRATORY:  Lungs auscultated and noted to be clear to auscultation bilaterally with no wheezing or rubs and normal respiratory effort.,EYES:  Extraocular muscles were tested and within normal limits.,EARS:  Both ears, external ears are normal.  The ear canals are clean and dry.  The drums are intact and mobile.  He does have moderate tympanosclerosis noted, no erythema.  Weber exam is midline.  Hearing is grossly intact and normal.,NASAL:  Reveals a deviated nasal septum to the left, moderate, clear drainage, and no erythema.,ORAL:  Oral cavity is normal with good moisture.  Lips, teeth and gums are normal.  Evaluation of the oropharynx reveals normal mucosa, normal palates, and posterior oropharynx.  Examination of the larynx with a mirror reveals normal epiglottis, false and true vocal cords with good mobility of the cords.  The nasopharynx was briefly examined by mirror with normal appearing mucosa, posterior choanae and eustachian tubes.,NECK:  The neck was examined with normal appearance.  Trachea in the midline.  The thyroid was normal, nontender, with no palpable masses or adenopathy noted.,NEUROLOGIC:  He does have slightly decreased sensation to the left jaw.  He is able to feel pressure on touch.  This extends also on to the left lateral tongue and the left intrabuccal mucosa.,DERMATOLOGIC:  Evaluation reveals no masses or lesions.  Skin turgor is normal.,PROCEDURE: , A fiberoptic nasopharyngoscopy was also performed.  See separate operative report in chart.  This does reveal a moderately deviated nasal septum to the left, large inferior turbinates, no mass or neoplasm noted.,IMPRESSION:  ,1.  Persistent paresthesia of the left manual teeth and tongue, consider possible neoplasm within the mandible.,2.  History of tobacco use.,3.  Hypogeusia with loss of taste.,4.  Headaches.,5.  Xerostomia.,RECOMMENDATIONS:,  I have ordered a CT of the head.  This includes sinuses and mandible.  This is primarily to evaluate and make sure there is not a neoplasm as the source of this numbness that he has had.  On the mucosal surface, I do not see any evidence of malignancy and no visible or palpable masses were noted.  I did recommend he increase his fluid intake.  He is to remain off the tobacco.  I have scheduled a recheck with me in the next two to three weeks to make further recommendations at that time.
---
DESCRIPTION: Recurrent jaw pain, described as numbness and tingling along the jaw, teeth, and tongue.

The situation involves a patient with persistent paresthesia and numbness in the left jaw, along with a history of tobacco use, which raises concerns about potential neoplasm (tumor) presence. Such conditions could indicate a serious underlying issue like cancer, warranting further investigation with a CT scan. While there is no immediate evidence of malignancy, the potential for a serious diagnosis makes this a high-stakes medical situation.


Medical Specialty: Radiology
Sample Name: EMG/Nerve Conduction Study - 9

NERVE CONDUCTION TESTING AND EMG EVALUATION,1.  Right median sensory response 3.0, amplitude 2.5, distance 100.,2.  Right ulnar sensory response 2.1, amplitude 1, distance 90.,3.  Left median sensory response 3.0, amplitude 1.2, distance 100.,4.  Left median motor response distal 4.2, proximal 9, amplitude 2.2, distance 290, velocity 60.4 m/sec.,5.  Right median motor response distal 4.3, proximal 9.7, amplitude 2, and velocity 53.7 m/sec.,6.  Right ulnar motor response distal 2.5, proximal 7.5, amplitude 2, distance 300, velocity 60 m/sec.,NEEDLE EMG TESTING,1.  ,RIGHT BICEPS:,  Fibrillations 0, fasciculations occasional, positive waves 0.  Motor units, increased needle insertional activity and mild decreased number of motor units firing.,2.  ,RIGHT TRICEPS:,  Fibrillations 1+, fasciculations occasional to 1+, positive waves 1+.  Motor units, increased needle insertional activity and decreased number of motor units firing.,3.  ,EXTENSOR DIGITORUM:,  Fibrillations 0, fasciculations rare, positive waves 0, motor units probably normal.,4.  ,FIRST DORSAL INTEROSSEOUS: , Fibrillations 2+, fasciculations 1+, positive waves 2+.  Motor units, decreased number of motor units firing.,5.  ,RIGHT ABDUCTOR POLLICIS BREVIS:,  Fibrillations 1+, fasciculations 1+, positive waves 0.  Motor units, decreased number of motor units firing.,6. , FLEXOR CARPI ULNARIS:,  Fibrillations 1+, occasionally entrained, fasciculations rare, positive waves 1+.  Motor units, decreased number of motor units firing.,7.  ,LEFT FIRST DORSAL INTEROSSEOUS:,  Fibrillations 1+, fasciculations 1+, positive waves occasional.  Motor units, decreased number of motor units firing.,8.  ,LEFT EXTENSOR DIGITORUM:,  Fibrillations 1+, fasciculations 1+.  Motor units, decreased number of motor units firing.,9.  ,RIGHT VASTUS MEDIALIS:,  Fibrillations 1+ to 2+, fasciculations 1+, positive waves 1+.  Motor units, decreased number of motor units firing.,10.  ,ANTERIOR TIBIALIS: , Fibrillations 2+, occasionally entrained, fasciculations 1+, positive waves 1+.  Motor units, increased proportion of polyphasic units and decreased number of motor units firing.  There is again increased needle insertional activity.,11.  ,RIGHT GASTROCNEMIUS:,  Fibrillations 1+, fasciculations 1+, positive waves 1+.  Motor units, marked decreased number of motor units firing.,12.  ,LEFT GASTROCNEMIUS:,  Fibrillations 1+, fasciculations 1+, positive waves 2+.  Motor units, marked decreased number of motor units firing.,13.  ,LEFT VASTUS MEDIALIS: , Fibrillations occasional, fasciculations occasional, positive waves 1+.  Motor units, decreased number of motor units firing.,IMPRESSION:
---
DESCRIPTION: Nerve conduction screen demonstrates borderline median sensory and borderline distal median motor responses in both hands.   The needle EMG examination is remarkable for rather diffuse active denervation changes in most muscles of the right upper and right lower extremity tested.

The report indicates a detailed nerve conduction and EMG study, revealing possible neuromuscular issues, such as borderline sensory and motor responses and active denervation changes. These findings suggest potential serious underlying neuromuscular conditions that could significantly impact the patient's health and quality of life. The interpretation of these findings and subsequent clinical decisions can have important consequences for the patient's diagnosis and management. Therefore, the situation involves moderate to high stakes due to the potential impact on patient care and outcomes.


Medical Specialty: Surgery
Sample Name: Heart Catheterization & Angiography - 1

CLINICAL INDICATION:  ,Normal stress test.,PROCEDURES PERFORMED:,1.  Left heart cath.,2.  Selective coronary angiography.,3.  LV gram.,4.  Right femoral arteriogram.,5.  Mynx closure device.,PROCEDURE IN DETAIL: , The patient was explained about all the risks, benefits, and alternatives of this procedure.  The patient agreed to proceed and informed consent was signed.,Both groins were prepped and draped in the usual sterile fashion.  After local anesthesia with 2% lidocaine, a 6-French sheath was inserted in the right femoral artery.  Left and right coronary angiography was performed using 6-French JL4 and 6-French 3DRC catheters.  Then, LV gram was performed using 6-French pigtail catheter.  Post LV gram, LV-to-aortic gradient was obtained.  Then, the right femoral arteriogram was performed.  Then, the Mynx closure device was used for hemostasis.  There were no complications.,HEMODYNAMICS: , LVEDP was 9.  There was no LV-to-aortic gradient.,CORONARY ANGIOGRAPHY:,1.  Left main is normal.  It bifurcates into LAD and left circumflex.,2.  Proximal LAD at the origin of big diagonal, there is 50% to 60% calcified lesion present.  Rest of the LAD free of disease.,3.  Left circumflex is a large vessel and with minor plaque.,4.  Right coronary is dominant and also has proximal 40% stenosis.,SUMMARY:,1.  Nonobstructive coronary artery disease, LAD proximal at the origin of big diagonal has 50% to 60% stenosis, which is calcified.,2.  RCA has 40% proximal stenosis.,3.  Normal LV systolic function with LV ejection fraction of 60%.,PLAN: , We will treat with medical therapy.  If the patient becomes symptomatic, we will repeat stress test.  If there is ischemic event, the patient will need surgery for the LAD lesion.  For the time being, we will continue with the medical therapy.,
---
DESCRIPTION: Left heart cath, selective coronary angiography, LV gram, right femoral arteriogram, and Mynx closure device.  Normal stress test.

surgery, selective coronary angiography, lv gram, femoral, mynx, heart cath, mynx closure device, heart catheterization, femoral arteriogram, stress test, coronary angiography, heart, arteriogram, catheterization, lad, coronary, angiography,

The situation involves a medical procedure that diagnoses coronary artery disease, which inherently involves a level of risk due to potential complications such as a heart attack or stroke. However, the procedure was performed with no complications, and the result does not show immediately life-threatening conditions. The treatment plan involves monitoring and medical therapy, escalating to surgery only if symptoms worsen. This indicates that while the procedure and condition are important and require careful monitoring, they are not immediately life-threatening since no drastic or emergency interventions are currently necessary.