Medical Specialty: Surgery
Sample Name: Cardiac Catheterization - 2

INDICATIONS FOR PROCEDURE:, The patient has presented with atypical type right arm discomfort and neck discomfort. She had noninvasive vascular imaging demonstrating suspected right subclavian stenosis. Of note, there was bidirectional flow in the right vertebral artery, as well as 250 cm per second velocities in the right subclavian. Duplex ultrasound showed at least a 50% stenosis.,APPROACH:, Right common femoral artery.,ANESTHESIA:, IV sedation with cardiac catheterization protocol. Local infiltration with 1% Xylocaine.,COMPLICATIONS:, None.,ESTIMATED BLOOD LOSS:, Less than 10 ml.,ESTIMATED CONTRAST:, Less than 250 ml.,PROCEDURE PERFORMED:, Right brachiocephalic angiography, right subclavian angiography, selective catheterization of the right subclavian, selective aortic arch angiogram, right iliofemoral angiogram, 6 French Angio-Seal placement.,DESCRIPTION OF PROCEDURE:, The patient was brought to the cardiac catheterization lab in the usual fasting state. She was laid supine on the cardiac catheterization table, and the right groin was prepped and draped in the usual sterile fashion. 1% Xylocaine was infiltrated into the right femoral vessels. Next, a #6 French sheath was introduced into the right femoral artery via the modified Seldinger technique.,AORTIC ARCH ANGIOGRAM:, Next, a pigtail catheter was advanced to the aortic arch. Aortic arch angiogram was then performed with injection of 45 ml of contrast, rate of 20 ml per second, maximum pressure 750 PSI in the 4 degree LAO view.,SELECTIVE SUBCLAVIAN ANGIOGRAPHY:, Next, the right subclavian was selectively cannulated. It was injected in the standard AP, as well as the RAO view. Next pull back pressures were measured across the right subclavian stenosis. No significant gradient was measured.,ANGIOGRAPHIC DETAILS:, The right brachiocephalic artery was patent. The proximal portion of the right carotid was patent. The proximal portion of the right subclavian prior to the origin of the vertebral and the internal mammary showed 50% stenosis.,IMPRESSION:,1. Moderate grade stenosis in the right subclavian artery.,2. Patent proximal edge of the right carotid.
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DESCRIPTION: The patient with atypical type right arm discomfort and neck discomfort.

surgery, discomfort, subclavian stenosis, artery, french angio-seal, lao view, rao view, aortic arch angiogram, arch angiogram, cardiac catheterization, aortic arch, brachiocephalic, cardiac, angiography, aortic, angiogram, stenosis, catheterization, atypical, subclavian,

Cardiac catheterization is an invasive procedure that involves accessing the heart and surrounding blood vessels. The case involves angiography for a patient with suspected stenosis, which is a narrowing of blood vessels. Although there were no complications noted, the procedure itself holds moderate risk due to its invasive nature, potential for vascular damage, and importance in diagnosing and potentially treating cardiovascular conditions. However, since this is a diagnostic procedure with low estimated blood loss and the absence of immediate procedural complications, it does not reach the highest levels of criticality.


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

Medical Specialty: Obstetrics / Gynecology
Sample Name: Laser of Vulva

PREOPERATIVE DIAGNOSIS: , Recurrent dysplasia of vulva.,POSTOPERATIVE DIAGNOSIS:,  Same.,OPERATION PERFORMED:,  Carbon dioxide laser photo-ablation.,ANESTHESIA: , General, laryngeal mask.,INDICATIONS FOR PROCEDURE: , The patient has a past history of recurrent vulvar dysplasia.  She has had multiple prior procedures for treatment.  She was counseled to undergo laser photo-ablation.,FINDINGS:,  Examination under anesthesia revealed several slightly raised and pigmented lesions, predominantly on the left labia and perianal regions.  After staining with acetic acid, several additional areas of acetowhite epithelium were seen on both sides and in the perianal region.,PROCEDURE:  ,The patient was brought to the operating room with an IV in place.  Anesthetic was administered, after which she was placed in the lithotomy position.  Examination under anesthesia was performed, after which she was prepped and draped.  Acetic acid was applied and marking pen was utilized to outline the extent of the dysplastic lesion.  The carbon dioxide laser was then used to ablate the lesion to the third surgical plane as defined Reid.  Setting was 25 watts using a 6 mm pattern size with the silk-touch hand piece in the paint mode.  Excellent hemostasis was noted and Bacitracin was applied prophylactically.  The patient was awakened from her anesthetic and taken to the Post Anesthesia Care Unit in stable condition.
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DESCRIPTION: Carbon dioxide laser photo-ablation due to recurrent dysplasia of vulva.

obstetrics / gynecology, laser of vulva, recurrent dysplasia, carbon dioxide laser photo-ablation, recurrent dysplasia of vulva, dysplasia of vulva, carbon dioxide laser, photo ablation, carbon, dysplasia, laser, ablation,

The procedure described involves the surgical treatment of recurrent vulvar dysplasia using a carbon dioxide laser. While this is considered a serious medical condition that requires attention due to its recurring nature and potential risks (such as progression to cancer if untreated), the procedure itself is a routine surgical intervention in the field of obstetrics and gynecology. The use of general anesthesia also adds some level of risk, but it is standard in such procedures. Overall, this situation is moderately high-stakes due to the potential for disease progression, but it is mitigated by the routine nature of the operation and the patient's stable postoperative condition.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Mayoview - 2

LEXISCAN MYOVIEW STRESS STUDY,REASON FOR THE EXAM: , Chest discomfort.,INTERPRETATION: , The patient exercised according to the Lexiscan study, received a total of 0.4 mg of Lexiscan IV injection.  At peak hyperemic effect, 24.9 mCi of Myoview were injected for the stress imaging and earlier 8.2 mCi were injected for the resting and the usual SPECT and gated SPECT protocol was followed and the data was analyzed using Cedars-Sinai software.  The patient did not walk because of prior history of inability to exercise long enough on treadmill.,The resting heart rate was 57 with the resting blood pressure 143/94.  Maximum heart rate achieved was 90 with a maximum blood pressure unchanged.,EKG at rest showed sinus rhythm with no significant ST-T wave changes of reversible ischemia or injury.  Subtle nonspecific in III and aVF were seen.  Maximum stress test EKG showed inverted T wave from V4 to V6.  Normal response to Lexiscan.,CONCLUSION:  ,Maximal Lexiscan perfusion with subtle abnormalities non-conclusive.  Please refer to the Myoview interpretation.,MYOVIEW INTERPRETATION: , The left ventricle appeared to be normal in size on both stress and rest with no change between the stress and rest with left ventricular end-diastolic volume of 115 and end-systolic of 51.  EF estimated and calculated at 56%.,Cardiac perfusion reviewed, showed no reversible defect indicative of myocardium risk and no fixed defect indicative of myocardial scarring.,IMPRESSION:,1.  Normal stress/rest cardiac perfusion with no indication of ischemia.,2.  Normal LV function and low likelihood of significant epicardial coronary narrowing.,
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DESCRIPTION: Lexiscan myoview stress study.  Chest discomfort.  Normal stress/rest cardiac perfusion with no indication of ischemia.  Normal LV function and low likelihood of significant epicardial coronary narrowing.

cardiovascular / pulmonary, chest discomfort, lexiscan myoview stress study, mci, spect, gated spect, myoview, lexiscan, stress test, ekg, lexiscan myoview, lv function, coronary narrowing, heart rate, blood pressure, myoview interpretation, cardiac perfusion, cardiac, ischemia, perfusion, stress,

The situation involves the interpretation of a cardiovascular imaging study for a patient experiencing chest discomfort. While this pertains to a sensitive area of health—potential heart issues—the results indicate normal cardiac perfusion and normal left ventricular function, suggesting no immediate threat of heart ischemia or permanent damage, and low likelihood of coronary narrowing. Despite the medical context, the absence of critical findings significantly reduces the urgency and stakes of the situation.


Medical Specialty: Surgery
Sample Name: Closing Wedge Osteotomy

PREOPERATIVE DIAGNOSIS: , Tailor's bunion, right foot.,POSTOPERATIVE DIAGNOSIS: , Tailor's bunion, right foot.,PROCEDURE: , Closing wedge osteotomy, fifth metatarsal with internal screw fixation, right foot.,ANESTHESIA: , Local infiltrate with IV sedation.,INDICATIONS FOR SURGERY: , The patient has had a longstanding history of foot problems.  The problem has been progressive in nature.  The preoperative discussion with the patient included alternative treatment options, the procedure was explained, and the risk factors such as infection, swelling, scar tissue, numbness, continued pain, recurrence, and the postoperative management were discussed.  The patient has been advised, although no guarantee for success could be given, most of the patient have less pain and improved function, all questions were thoroughly answered.  The patient requested for surgical repair since the problem has reached a point that interfere with normal daily activity.  The purpose of the surgery is to alleviate pain and discomfort.,DETAILS OF PROCEDURE:  ,The patient was given 1 g of Ancef IV for antibiotic prophylaxis 30 minutes prior to the procedure.  The patient was brought to the operating room and placed in the supine position.  No tourniquet was utilized.  IV sedation was achieved followed by a local anesthetic consisting of approximately 10 mL total in 1:1 mixture of 0.25% Marcaine and 1% lidocaine with epinephrine was locally infiltrated proximal to the operative site.  The lower extremity was prepped and draped in the usual sterile manner.  Balanced anesthesia was obtained.,PROCEDURE:, Closing wedge osteotomy, fifth metatarsal with internal screw fixation, right foot.  A dorsal curvilinear incision was made extending from the base of the proximal phalanx fifth digit to a point 1.5 cm from the base of the fifth metatarsal.  Care was taken to identify and retract all vital structures and when necessary, vessels were ligated via electrocautery.  The extensor tendon was identified and retracted medially.  Sharp and blunt dissection was carried down through the subcutaneous tissue down to the periosteal layer.  A linear periosteal capsular incision was made in line with the skin incision.  The capsular tissue and periosteal layer was underscored, free from its underlying osseous attachment, and then reflected to expose the osseous surface.  Inspection of the fifth metatarsophalangeal joint revealed articular cartilage to be perverse and hypertrophic changes to the lateral and dorsolateral aspect of the fifth metatarsal head.  An oscillating saw was utilized to carefully resect the hypertrophic portion of the fifth metatarsal head to a more normal configuration.  The both edges were rasped smooth.,Attention was then focused on the fifth metatarsal.  The periosteal layer proximal to the fifth metatarsal head was underscored, free from its underlying attachment, and then reflected to expose the osseous surface.  An excess guide position perpendicular to the weightbearing surface was placed to define apex of the osteotomy.,Using an oscillating saw, a vertically placed, wedge-shaped oblique ostomy was made with the apex being proximal, lateral, and the base medial and distal.  Generous amounts of lateral cortex were preserved for the lateral hinge.  The wedge was removed from the surgical field.  The fifth metatarsal was placed in the appropriate position and stabilized with a guide pin, which was then countersunk and a 3-0 x 40 mm cannulated cortical screw was placed over the guide pin and secured into position.  Good purchase was noted at the osteotomy site.  Inspection revealed satisfactory reduction of the fourth intermetatarsal angle with the fifth metatarsal in good alignment and position.  The surgical site was flushed with copious amounts of normal saline irrigation.  The periosteal and capsular layers were closed with running sutures of 3-0 Vicryl.  The subcutaneous tissues were closed with 4-0 Vicryl, and the skin edges were closed with 4-0 nylon in a running interrupted fashion.  A dressing consisting of Adaptic, 4 x 4, confirming bandages, and ACE wrap to provide mild compression was applied.  The patient tolerated the procedure and anesthesia well and left the operating room to the recovery room in good postoperative condition with vital signs stable and arterial perfusion intact as evident by normal capillary refill time, and all digits were warm and pink.,A walker boot was dispensed and applied.  The patient should wear that all the time when standing or walking and be nonweightbearing with crutches and to clear by me.,Office visit will be in 4 days.  The patient was given prescriptions for Keflex 500 mg one p.o. t.i.d. for 10 days and Ultram ER, #15 one p.o. daily along with written and oral home instructions including a number on which I can be reached 24 hours a day if any problem arises.,After short recuperative period, the patient was discharged home with a vital sign stable in no acute distress.
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DESCRIPTION: Closing wedge osteotomy, fifth metatarsal with internal screw fixation, right foot.

surgery, internal screw fixation, osteotomy, closing wedge osteotomy, tailor's bunion, screw fixation, periosteal layer, metatarsal head, wedge osteotomy, metatarsal, anesthesia

The scenario describes a surgical procedure, specifically a closing wedge osteotomy, which is a planned and routine orthopedic intervention to address a Tailor's bunion. The stakes are considered moderate-to-high due to the inherent risks associated with surgical procedures (such as infection, improper bone healing, etc.) and the impact on the patient's mobility and quality of life. However, this is not an emergency surgery, and the patient was well informed of risks and alternatives, suggesting a controlled and planned environment.


Medical Specialty: Orthopedic
Sample Name: Foreign Body Removal - Foot

PREOPERATIVE DIAGNOSIS: , Foreign body, right foot.,POSTOPERATIVE DIAGNOSIS: , Foreign body in the right foot.,PROCEDURE PERFORMED:,  Excision of foreign body, right foot and surrounding tissue.,ANESTHESIA: , TIVA and local.,HISTORY:,  This 41-year-old male presents to preoperative holding area after keeping himself n.p.o., since mid night for removal of painful retained foreign body in his right foot.  The patient works in the Electronics/Robotics field and relates that he stepped on a wire at work, which somehow got into his shoe.  The wire entered his foot.  His family physician attempted to remove the wire, but it only became deeper in the foot.  The wound eventually healed, but a scar tissue was formed.  The patient has had constant pain with ambulation intermittently since the incident occurred.  He desires attempted surgical removal of the wire.  The risks and benefits of the procedure have been explained to the patient in detail by Dr. X.  The consent is available on the chart for review.,PROCEDURE IN DETAIL: , After IV was established by the Department of Anesthesia, the patient was taken to the operating room via cart and placed on the operating table in a supine position with a safety strap placed across his waist for his protection.,A pneumatic ankle tourniquet was applied about the right ankle over copious amounts of Webril for the patient's protection.  After adequate IV sedation was administered by the Department of Anesthesia, a total of 12 cc of 0.5% Marcaine plain was used to administer an ankle block.  Next, the foot was prepped and draped in the usual aseptic fashion.  An Esmarch bandage was used to exsanguinate the foot and the pneumatic ankle tourniquet was elevated to 250 mmHg.  The foot was lowered into the operative field and the sterile stockinet was reflected.  Attention was directed to the plantar aspect of the foot where approximately a 5 mm long cicatrix was palpated and visualized.  This was the origin and entry point of the previous puncture wound from the wire.  This cicatrix was found lateral to the plantar aspect of the first metatarsal between the first and second metatarsals in a nonweightbearing area.  Next, the Xi-scan was draped and brought into the operating room.  A #25 gauge needles under fluoroscopy were inserted into the plantar aspect of the foot and three planes to triangulate the wire.  Next, a #10 blade was used to make approximately a 3 cm curvilinear "S"-shaped incision.  Next, the #15 blade was used to carry the incision through the subcutaneous tissue.  The medial and lateral margins of the incision were undermined.  Due to the small nature of the foreign body and the large amount of fat on the plantar aspect of the foot, the wires seemed to serve no benefit other then helping with the incision planning.  Therefore, they were removed.  Once the wound was opened, a hemostat was used to locate the wire very quickly and the wire was clamped.  A second hemostat was used to clamp the wire.  A #15 blade was used to carefully transect the fatty tissue around the tip of the hemostats, which were visualized in the base of the wound.  The wire quickly came into visualization.  It measured approximately 4 mm in length and was approximately 1 mm in diameter.  The wire was green colored and metallic in nature.  It was removed with the hemostat and passed off as a specimen to be sent to Pathology for identification.  The wire was found at the level of deep fascia at the capsular level just plantar to the deep transverse intermetatarsal ligament.  Next, copious amounts of sterile gentamicin impregnated saline was instilled in the wound for irrigation and the wound base was thoroughly cleaned and inspected.  Next, a #3-0 Vicryl was used to throw two simple interrupted deep sutures to remove the dead space.  Next, #4-0 Ethibond was used to close the skin in a combination of simple interrupted and horizontal mattress suture technique.  The standard postoperative dressing consisting of saline-soaked Owen silk, 4x4s, Kling, Kerlix, and Coban were applied.  The pneumatic ankle tourniquet was released.  There was immediate hyperemic flush to the digits noted.  The patient's anesthesia was reversed.  He tolerated the above anesthesia and procedure without complications.  The patient was transported via cart to the Postanesthesia Care Unit.,Vital signs were stable and vascular status was intact to the right foot.  He was given OrthoWedge shoe.  Ice was applied behind the knee and his right lower extremity was elevated on to pillows.  He was given standard postoperative instructions consisting of rest, ice and elevation to the right lower extremity.  He is to be non-weightbearing for three weeks, at which time, the wound will be evaluated and sutures will be removed.  He is to follow up with Dr. X on 08/22/2003 and was given emergency contact number to call if problems arise.  He was given a prescription for Tylenol #4, #30 one p.o. q.4-6h. p.r.n., pain as well as Celebrex 200 mg #30 take two p.o. q.d. p.c., with 200 mg 12 hours later as a rescue dose.  He was given crutches.  He was discharged in stable condition.
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DESCRIPTION: Excision of foreign body, right foot and surrounding tissue.  This 41-year-old male presents to preoperative holding area after keeping himself n.p.o., since mid night for removal of painful retained foreign body in his right foot.  The patient works in the Electronics/Robotics field and relates that he stepped on a wire at work, which somehow got into his shoe.  The wire entered his foot.

orthopedic, foreign body removal, excision of foreign body, ankle tourniquet, plantar aspect, foreign body, foot, ankle, plantar, wound,

The procedure described involves the surgical removal of a foreign body from a patient's foot, which is a relatively routine procedure in orthopedic surgery. The patient has experienced pain from the foreign body for some time, but the surgery is elective rather than emergent, as it has been planned and consented to. The risks involved, such as infection or potential complications from anesthesia, exist but are standard and manageable within the context of surgical procedures. The postoperative care plan indicates that the procedure was successful without complications, further reducing the stakes. Therefore, while this requires surgical intervention and a certain degree of medical precision, it doesn't constitute a high-stakes medical situation overall.


Medical Specialty: Radiology
Sample Name: MRI Brain -  Meningioma (Olfactory)

CC:, Progressive visual loss.,HX:, 76 y/o male suddenly became anosmic following shoulder surgery 13 years prior to this presentation. He continues to be anosmic, but has also recently noted decreased vision OD. He denies any headaches, weakness, numbness, weight loss, or nasal discharge.,MEDS:, none.,PMH:, 1) Diabetes Mellitus dx 1 year ago. 2) Benign Prostatic Hypertrophy, s/p TURP. 3) Right shoulder surgery (?DJD).,FHX:, noncontributory.,SHX:, Denies history of Tobacco/ETOH/illicit drug use.,EXAM:, BP132/66 HR78 RR16 36.0C,MS: A&O to person, place, and time. No other specifics given in Neurosurgery/Otolaryngology/Neuro-ophthalmology notes.,CN: Visual acuity has declined from 20/40 to 20/400, OD; 20/30, OS. No RAPD. EOM was full and smooth and without nystagmus. Goldmann visual fields revealed a central scotoma and enlarged blind spot OD and OS (OD worse) with a normal periphery. Intraocular pressures were 15/14 (OD/OS). There was moderate pallor of the disc, OD. Facial sensation was decreased on the right side (V1 distribution).,Motor/Sensory/Coord/Station/Gait: were all unremarkable.,Reflexes: 2/2 and symmetric throughout. Plantars were flexor, bilaterally.,Gen Exam: unremarkable.,COURSE:, MRI Brain, 10/7/92, revealed: a large 6x5x6cm slightly heterogeneous, mostly isointense lesion on both T1 and T2 weighted images arising from the planum sphenoidale and olfactory groove. The mass extends approximately 3.6cm superior to the planum into both frontal regions with edema in both frontal lobes. The mass extends 2.5cm inferiorly involving the ethmoid sinuses with resultant obstruction of the sphenoid and frontal sinuses.,It also extends into the superomedial aspect of the right maxillary sinus. There is probable partial encasement of both internal carotid arteries just above the siphon. The optic nerves are difficult to visualize but there is also probable encasement of these structures as well. The mass enhances significantly with gadolinium contrast. These finds are consistent with Meningioma.,The patient underwent excision of this tumor by simultaneous bifrontal craniotomy and lateral rhinotomy following an intrasinus biopsy which confirmed the meningioma. Postoperatively, he lost visual acuity, OS, but this gradually returned to baseline. His 9/6/96 neuro-ophthalmology evaluation revealed visual acuity of 20/25-3 (OD) and 20/80-2 (OS). His visual fields continued to abnormal, but improved and stable when compared to 10/92. His anosmia never resolved.
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DESCRIPTION: MRI Brain - Olfactory groove meningioma.

radiology, mri brain, olfactory, groove, headaches, meningioma, nasal discharge, numbness, visual loss, weakness, weight loss, visual acuity, mri, brain, isointense, sinuses, visual,

The situation involves a detailed radiological medical case where a patient has a large brain meningioma causing significant symptoms like anosmia and vision loss. Surgical intervention was needed, and there were postoperative complications affecting vision. The case involves high-stakes medical decisions and procedures with potential life-altering outcomes for the patient's sensory functions and overall quality of life.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Transesophageal Echocardiogram - 6

HISTORY OF PRESENT ILLNESS: , I was kindly asked to see this patient for transesophageal echocardiogram performance by Dr. A and Neurology.  Please see also my cardiovascular consultation dictated separately.  But essentially, this is a pleasant 72-year-old woman admitted to the hospital with a large right MCA CVA causing a left-sided neurological deficit incidentally found to have atrial fibrillation on telemetry.  She has been recommended for a transesophageal echocardiogram for cardioembolic source of her CNS insult.,I discussed the procedure in detail with the patient as well as with her daughter, who was present at the patient's bedside with the patient's verbal consent.  I then performed a risk/benefit/alternative analysis with benefits being more definitive exclusion of intracardiac thrombus as well as assessment for intracardiac shunts; alternatives being transthoracic echo imaging, which she had already had, with an inherent false negativity for this indication as well as empiric medical management, which the patient was not interested in; risks including, but not limited to, and the patient was aware this was not an all-inclusive list, of oversedation from conscious sedation, risk of aspiration pneumonia from regurgitation of stomach contents, risk of oropharyngeal, esophageal, oral, tracheal, pulmonary and/or gastric perforation, hemorrhage, or tear.  The patient expressed understanding of this risk/benefit/alternative analysis, had the opportunity to ask questions, which I invited from her and her daughter, all of which were answered to their self-stated satisfaction.  The patient then stated in a clear competent and coherent fashion that she wished to go forward with the transesophageal echocardiogram.,PROCEDURE: , The appropriate time-out procedure was performed as per Medical Center protocol under my direct supervision with appropriate identification of the patient, position, physician, procedure documentation; there were no safety issues identified by staff nor myself.  She received 20 cc of viscous lidocaine for topical oral anesthetic effect.  She received a total of 4 mg of Versed and 100 micrograms of fentanyl utilizing titrated conscious sedation with continuous hemodynamic and oximetric monitoring with reasonable effect.  The multi-plane probe was passed using digital guidance for several passes, after an oral bite block had been put into place for protection of oral dentition.  This was placed into the posterior oropharynx and advanced into the esophagus, then advanced into the stomach and then rotated and withdrawn and removed with adequate imaging obtained throughout.  She was recovered as per the Medical Center conscious sedation protocol, and there were no apparent complications of the procedure.,FINDINGS: , Normal left ventricular size and systolic function.  LVEF of 60%.  Mild left atrial enlargement.  Normal right atrial size.  Normal right ventricular size and systolic function.  No left ventricular wall motion abnormalities identified.  The four pulmonary veins are identified.  The left atrial appendage is interrogated, including with Doppler and color flow, and while there is good to-and-fro motion seen, echo smoke is seen, and in fact, an intracardiac thrombus is identified and circumscribed at 1.83 cm in circumference at the base of the left atrial appendage.  No intracardiac vegetations nor endocarditis seen on any of the intracardiac valves.  The mitral valve is seen.  There is mild mitral regurgitation with two jets.  No mitral stenosis.  Four pulmonary veins were identified without reversible pulmonary venous flow.  There are three cusps of the aortic valve seen.  No aortic stenosis.  There is trace aortic insufficiency.  There is trace pulmonic insufficiency.  The pulmonary artery is seen and is within normal limits.  There is trace to mild tricuspid regurgitation.  Unable to estimate PA systolic pressure accurately; however, on the recent transthoracic echocardiogram (which I would direct the reader to) on January 5, 2010, RVSP was calculated at 40 mmHg on that study.  E wave velocity on average is 0.95 m/sec with a deceleration time of 232 milliseconds.  The proximal aorta is within normal limits, annulus 1.19 cm, sinuses of Valsalva 2.54 cm, ascending aorta 2.61 cm.  The intra-atrial septum is identified as are the SVC and IVC, and these are within normal limits.  The intra-atrial septum is interrogated with color flow as well as agitated D5W and there is no evidence of intracardiac shunting, including no atrial septal defect nor patent foramen ovale.  No pericardial effusion.  There is mild nonmobile descending aortic atherosclerosis seen.,IMPRESSION:,1.  Normal left ventricular size and systolic function.  Left ventricular ejection fraction visually estimated at 60% without regional wall motion abnormalities.,2.  Mild left atrial enlargement.,3.  Intracardiac thrombus identified at the base of the left atrial appendage.,4.  Mild mitral regurgitation with two jets.,5.  Mild nonmobile descending aortic atherosclerosis.,Compared to the transthoracic echocardiogram done previously, other than identification of the intracardiac thrombus, other findings appear quite similar.,These results have been discussed with Dr. A of inpatient Internal Medicine service as well as the patient, who was recovering from conscious sedation, and her daughter with the patient's verbal consent.
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DESCRIPTION: Transesophageal Echocardiogram.  A woman admitted to the hospital with a large right MCA CVA causing a left-sided neurological deficit incidentally found to have atrial fibrillation on telemetry.

cardiovascular / pulmonary, echo, thrombus, intracardiac, cardiovascular, pulmonary veins, intracardiac thrombus, transesophageal echocardiogram, echocardiogram, atrial, mca, cva, transesophageal, pulmonary, ventricular, aortic

The situation involves a 72-year-old woman who has experienced a large MCA stroke and is found to have atrial fibrillation. A transesophageal echocardiogram was performed to investigate a cardioembolic source for her CNS insult. The procedure identified an intracardiac thrombus, which is significant because it provides a potential explanation for the stroke and can inform further treatment options like anticoagulation. The stakes are high because the presence of a thrombus can lead to further strokes or serious complications if not properly managed. However, the patient appears to be in stable condition post-procedure, and there were no immediate complications from the echocardiogram. Thus, the situation is not extremely high-stakes at the current moment but warrants significant concern and prompt medical management to prevent future high-stakes outcomes.


Medical Specialty: Radiology
Sample Name: CT Neck - 1

FINDINGS:,There is a lobulated mass lesion of the epiglottis measuring approximately 22 x 16 x 30 mm (mediolateral x AP x craniocaudal) in size. There is slightly greater involvement on the right side however there is bilateral involvement of the aryepiglottic folds. There is marked enlargement of the bilateral aryepiglottic folds (left greater than right). There is thickening of the glossoepiglottic fold. There is an infiltrative mass like lesion extending into the pre-epiglottic space.,There is no demonstrated effacement of the piriform sinuses. The mass obliterates the right vallecula. The paraglottic spaces are normal. The true and false cords appear normal. Normal thyroid, cricoid and arytenoid cartilages.,There is lobulated thickening of the right side of the tongue base, for which invasion of the tongue cannot be excluded. A MRI examination would be of benefit for further evaluation of this finding.,There is a 14 x 5 x 12 mm node involving the left submental region (Level I).,There is borderline enlargement of the bilateral jugulodigastric nodes (Level II). The left jugulodigastric node,measures 14 x 11 x 8 mm while the right jugulodigastric node measures 15 x 12 x 8 mm.,There is an enlarged second left high deep cervical node measuring 19 x 14 x 15 mm also consistent with a left Level II node, with a probable necrotic center.,There is an enlarged second right high deep cervical node measuring 12 x 10 x 10 mm but no demonstrated central necrosis.,There is an enlarged left mid level deep cervical node measuring 9 x 16 x 6 mm, located inferior to the hyoid bone but cephalad to the cricoid consistent with a Level III node.,There are two enlarged matted nodes involving the right mid level deep cervical chain consistent with a right Level III nodal disease, producing a conglomerate nodal mass measuring approximately 26 x 12 x 10 mm.,There is a left low level deep cervical node lying along the inferior edge of the cricoid cartilage measuring approximately 18 x 11 x 14 mm consistent with left Level IV nodal disease.,There is no demonstrated pretracheal, prelaryngeal or superior mediastinal nodes. There is no demonstrated retropharyngeal adenopathy.,There is thickening of the adenoidal pad without a mass lesion of the nasopharynx. The torus tubarius and fossa of Rosenmuller appear normal.,IMPRESSION:,Epiglottic mass lesion with probable invasion of the glossoepiglottic fold and pre-epiglottic space with invasion of the bilateral aryepiglottic folds.,Lobulated tongue base for which tongue invasion cannot be excluded. An MRI may be of benefit for further assessment of this finding.,Borderline enlargement of a submental node suggesting Level I adenopathy.,Bilateral deep cervical nodal disease involving bilateral Level II, Level III and left Level IV.
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DESCRIPTION: CT REPORT - Soft Tissue Neck

CT REPORT - Soft Tissue Neck

radiology, deep cervical node, epiglottic mass, epiglottic space, aryepiglottic folds, jugulodigastric nodes, level deep, cervical node, deep cervical, node, jugulodigastric, aryepiglottic, deep, cervical

The CT neck scan reveals significant abnormalities such as a mass lesion of the epiglottis, probable invasion of related structures, and extensive nodal enlargement. These findings suggest a potential malignancy or severe pathology, which could significantly impact the patient's treatment plan and prognosis. Given the involvement of critical areas of the neck, this situation is high-stakes as it may necessitate surgical intervention, further imaging, or oncological treatment. Early and accurate diagnosis and management are essential to prevent further complications.


Medical Specialty: Consult - History and Phy.
Sample Name: Orthopedic Consult - 5

Chief Complaint:, Back and hip pain.,History of Present Illness:, The patient is a 73 year old Caucasian male with a history of hypertension, end-stage renal disease secondary to reflux nephropathy / restriction of bladder neck requiring hemodialysis and eventual cadaveric renal transplant now on chronic immunosuppression, peripheral vascular disease with non-healing ulcer of right great toe, and peripheral neuropathy who initially presented to his primary care physician in May 2001 with complaints of low back pain and bilateral hip pain. The pain was described as a constant pain in the middle to lower back and hips. The pain was exacerbated by climbing stairs and in the morning after sleeping. He reported occasional radiation of pain from back into buttocks (greatest on the right side). He has history of chronic feet and leg numbness and paraesthesias related to his neuropathy, but he denied any recent changes in these symptoms in relation to the back pain. He denied any history of trauma. He was treated symptomatically with Acetaminophen with only some relief. He continued to complain intermittently of pain in his back and hips, and occasionally even in his elbows during the next 8 months. In January 2002, plain pelvic films showed no fracture or dislocation of the hips. Elbow films also showed no acute injury, but there were some erosions along the posterior aspect of the olecranon. An MRI was performed of his lumbar spine which showed degenerative disk disease, spondylosis, and annular bulging/herniation at L4-L5 with resultant encroachment on the neural foramen. He was evaluated by neurosurgery, who felt he should not have surgery at this time. His pain continued and progressively worsened, becoming unresponsive to medical therapy including narcotics,In May 2002, as part of a vascular work-up for the patient’s non-healing right toe, an MRA showed extensive vascular disease in the vessels of both legs below the knees and evidence of bilateral trochanteric bursitis. It also revealed an abnormal enhancing lesion in the left proximal femur, the left iliac bone, the right iliac bone, and possibly the right tibia.,Past Medical History:,End stade renal disease secondary to reflux nephropathy,a. numerous related urinary tract infections,b. hemodialysis (1983-1988),c. s/p cadaveric renal transplant (1988),d. baseline creatinine about 2.3.,Hypertension,Peripheral vascular disease,a. history of right foot infected toenail and non-healing ulcer since 2000; receiving hyperbaric oxygen therapy; recent surgery on infected toe in March, 2002,Peripheral Neuropathy,Chronic anemia (on Epogen injections),History of several partial small bowel obstructions - six times during the last 10 years,Past Surgical History:,1. Tonsillectomy and adenoidectomy (1943),2. Left ureter re-implantation (1960),3. Repair of splenic artery aneurysm (1968),4. Left arm AV fistula graft placement and numerous procedures for dialysis access (1983-1988),5. Cadaveric renal transplant (1988),6. Cataract surgery in bilateral eyes,Medications:,1. Imuran 100mg po QD,2. Prednisone 7.5mg po QD,3. Aspirin 81mg po QD,4. Trental 400mg po TID,5. Norvasc 5mg po BID,6. Prinivil 20mg po BID,7. Hydralazine 50mg po Q6H,8. Clonidine TTS III on Thursdays,9. Terasozin 5mg po BID,10. Elavil 30mg po QHS,11. Vicodin 1-2tabs po Q6H prn,12. Epoetin SR 10,000Units SQ QM and F,13. Sodium bicarbonate 648mg po QD,14. Calcium carbonate 2gm po QID,15. Docusate sodium 100mg po QD,16. Chocolate Ensure one can po QID,17. Multivitamin,18. Vitamin E,Social History:, The patient is married with five children and lives with his wife. He is a retired engineer and real estate broker. He denies tobacco use. He drinks alcohol occasionally with up to three drinks a week. No history of drug abuse.,Allergies:, No known drug allergies.,Family History:
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DESCRIPTION: Patient with back and hip pain.

Patient with back and hip pain.

This case involves a 73-year-old male with multiple serious and chronic health conditions, including end-stage renal disease requiring a transplant and on chronic immunosuppression, peripheral vascular disease, non-healing ulcers, degenerative spine disease, and possible bone lesions. The complexity and seriousness of his medical conditions, alongside a history of worsening pain unresponsive to treatment, make this a high-stakes situation. These conditions may lead to further complications and require careful management, making the stakes high for both systemic and localized health outcomes.


Medical Specialty: Consult - History and Phy.
Sample Name: Gen Med Consult - 10

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

The medical consultation involves assessing a 77-year-old patient with joint pain potentially indicative of inflammatory arthritis, compounded by a complex medical history including a previous pulmonary embolism, diabetes, osteoporosis, and a recent infection. Identifying and managing the cause of the joint pain is important for the patient's quality of life and mobility, particularly given her age and comorbidities, but it does not involve life-threatening immediate decisions. Thus, while the stakes for the patient's day-to-day well-being and management of existing conditions are significant, they are not critically life-threatening at present. However, the need for further investigation into the arthritis points to an intermediate level of stakes.


Medical Specialty: Office Notes
Sample Name: Constipation - 1

Patient was informed by Dr. ABC that he does not need sleep study as per patient.,PHYSICAL EXAMINATION:,General:  Pleasant, brighter.,Vital signs:  117/78, 12, 56.,Abdomen:  Soft, nontender.  Bowel sounds normal.,ASSESSMENT AND PLAN:,1.  Constipation.  Milk of Magnesia 30 mL daily p.r.n., Dulcolax suppository twice a week p.r.n.,2.  CAD/angina.  See cardiologist this afternoon.,Call me if constipation not resolved by a.m., consider a Fleet enema then as discussed.,
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DESCRIPTION: Patient complains of constipation.  Has not had BM for two days.

office notes, constipation, bm, milk of magnesia, suppository, dulcolax, fleet enema,

The situation described is a routine medical office note documenting a common health issue (constipation) and a planned treatment. The stakes are relatively low because constipation, while uncomfortable, is typically not a severe condition and can be managed with over-the-counter treatments. The patient has a scheduled cardiology appointment, which indicates ongoing care for a potentially more serious condition (CAD/angina), but the immediate concern is about constipation. The plan includes easily accessible remedies and a clear call to action if constipation persists, minimizing risk.


Medical Specialty: Gastroenterology
Sample Name: Laparoscopic Cholecystectomy - 7

PREOPERATIVE DIAGNOSIS: , Cholecystitis and cholelithiasis.,POSTOPERATIVE DIAGNOSIS:  ,Cholecystitis and cholelithiasis.,TITLE OF PROCEDURE,1.  Laparoscopic cholecystectomy.,2.  Intraoperative cholangiogram.,ANESTHESIA:  ,General.,PROCEDURE IN DETAIL:  ,The patient was taken to the operative suite and placed in the supine position under general endotracheal anesthetic.  The patient received 1 gm of IV Ancef intravenously piggyback.  The abdomen was prepared and draped in routine sterile fashion.,A 1-cm incision was made at the umbilicus and a Veress needle was inserted.  Saline test was performed.  Satisfactory pneumoperitoneum was achieved by insufflation of CO2 to a pressure of 14 mmHg.  The Veress needle was removed.  A 10- to 11-mm cannula was inserted.  Inspection of the peritoneal cavity revealed a gallbladder that was soft and without adhesions to it.  It was largely mobile.  The liver had a normal appearance as did the peritoneal cavity.  A 5-mm cannula was inserted in the right upper quadrant anterior axillary line.  A second 5-mm cannula was inserted in the subcostal space.  A 10- to 11-mm cannula was inserted into the upper midline.,The gallbladder was reflected in a cephalad direction.  The gallbladder was punctured with the aspirating needle, and under C-arm fluoroscopy was filled with contrast, filling the intra- and extrahepatic biliary trees, which appeared normal.  Extra contrast was aspirated and the aspirating needle was removed.  The ampulla was grasped with a second grasper, opening the triangle of Calot.  The cystic duct was dissected and exposed at its junction with the ampulla, was controlled with a hemoclip, digitally controlled with two clips and divided.  This was done while the common duct was in full visualization.  The cystic artery was similarly controlled and divided.  The gallbladder was dissected from its bed and separated from the liver, brought to the outside through the upper midline cannula and removed.,The subhepatic and subphrenic spaces were irrigated thoroughly with saline solution.  There was oozing and bleeding from the lateral 5-mm cannula site, but this stopped spontaneously with removal of the cannula.  The subphrenic and subhepatic spaces were again irrigated thoroughly with saline until clear.  Hemostasis was excellent.  CO2 was evacuated and the camera removed.  The umbilical fascia was closed with 2-0 Vicryl, the subcu with 3-0 Vicryl, and the skin was closed with 4-0 nylon.  Sterile dressings were applied.  Sponge and needle counts were correct.
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DESCRIPTION: Cholecystitis and cholelithiasis.  Laparoscopic cholecystectomy and intraoperative cholangiogram.  The patient received 1 gm of IV Ancef intravenously piggyback.  The abdomen was prepared and draped in routine sterile fashion.

gastroenterology, cholangiogram, cholecystitis, cholelithiasis, ancef, endotracheal, umbilicus, veress needle, c-arm fluoroscopy, intraoperative cholangiogram, laparoscopic cholecystectomy, laparoscopic, cholecystectomy, gallbladder, cannula,

This situation involves a laparoscopic cholecystectomy, a common surgical procedure to remove the gallbladder due to cholecystitis and cholelithiasis. Although it is a routine procedure with a low complication rate, it is still a surgical intervention that requires general anesthesia and involves risks such as infection, bleeding, and potential injury to adjacent organs. It is important for the success and safety of the patient, contributing to a moderate-stakes scenario.


Medical Specialty: Surgery
Sample Name: Cemented Hemiarthroplasty & Biopsy

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

The case involves a surgical procedure, specifically a left hip cemented hemiarthroplasty and biopsy, performed on a patient with a closed displaced probable pathological fracture, possibly due to underlying malignancy. The stakes are relatively high because the patient has a history of malignant melanoma, which may have metastasized to the bone. The surgery itself is complex and involves risks associated with anesthesia, potential surgical complications, and the management of underlying pathology. However, the procedure was completed successfully without intraoperative complications, and the patient was stable post-operation. Given these factors, while the context of cancer history elevates concern, the controlled nature and successful completion of the surgery balance the stakes. Therefore, the situation can be considered moderately high-stakes.


Medical Specialty: Surgery
Sample Name: Salpingectomy & Cervical Dilatation

PREOPERATIVE DIAGNOSIS:,  Sterilization candidate.,POSTOPERATIVE DIAGNOSIS:,  Sterilization candidate.,PROCEDURE PERFORMED:,1.  Cervical dilatation.,2.  Laparoscopic bilateral partial salpingectomy.,ANESTHESIA: , General endotracheal.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:  ,Less than 50 cc.,SPECIMEN: , Portions of bilateral fallopian tubes.,INDICATIONS:,  This is a 30-year-old female gravida 4, para-3-0-1-3 who desires permanent sterilization.,FINDINGS: , On bimanual exam, the uterus is small, anteverted, and freely mobile.  There are no adnexal masses appreciated.  On laparoscopic exam, the uterus, bilateral tubes and ovaries appeared normal.  The liver margin and bowel appeared normal.,PROCEDURE: , After consent was obtained, the patient was taken to the operating room where general anesthetic was administered.  The patient was placed in dorsal lithotomy position and prepped and draped in the normal sterile fashion.  A sterile speculum was placed in the patient's vagina and the anterior lip of the cervix was grasped with a vulsellum tenaculum.  The uterus was then sounded to 7 cm.,The cervix was serially dilated with Hank dilators.  A #20 Hank dilator was left in place.  The sterile speculum was then removed.  Gloves were changed.  Attention was then turned to the abdomen where approximately a 10 mm transverse infraumbilical incision was made through the patient's previous scar.  The Veress needle was placed and 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.  A 11 mm trocar was then placed through this incision and the camera was placed with the above findings noted.  Two 5 mm step trocars were placed, one 2 cm superior to the pubic bone along the midline and the other approximately 7 cm to 8 cm to the left at the level of the umbilicus.  The Endoloop was placed through the left-sided port.  A grasper was placed in the suprapubic port and put through the Endoloop and then a portion of the left tube was identified and grasped with a grasper.  A knuckle of tube was brought up with the grasper and a #0 Vicryl Endoloop synched down across this knuckle of tube.  The suture was then cut using the endoscopic shears.  The portion of tube that was tied off was removed using a Harmonic scalpel.  This was then removed from the abdomen and sent to Pathology.  The right tube was then identified and in a similar fashion, the grasper was placed through the loop of the #0 Vicryl Endoloop and the right tube was grasped with the grasper and the knuckle of tube was brought up into the loop.  The loop was then synched down.  The Endoshears were used to cut the suture.  The Harmonic scalpel was then used to remove that portion of tube.  The portion of the tube that was removed from the abdomen was sent to Pathology.  Both tubes were examined and found to have excellent hemostasis.  All instruments were then removed.  The 5 mm ports were removed with good 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 fascia of the infraumbilical incision was reapproximated with an interrupted suture of #3-0 Vicryl.  The skin was then closed with #4-0 undyed Vicryl in a subcuticular fashion.  Approximately 10 cc of Marcaine was injected at the incision site.  The vulsellum tenaculum and cervical dilator were then 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 the procedure.  The patient was taken to the recovery room in satisfactory condition.  She will be discharged home with a prescription for Vicodin for pain and was instructed to follow up in the office in two weeks.
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DESCRIPTION: Sterilization candidate.  Cervical dilatation and laparoscopic bilateral partial salpingectomy.  A 30-year-old female gravida 4, para-3-0-1-3 who desires permanent sterilization.

surgery, cervical dilatation, partial salpingectomy, permanent sterilization, vulsellum tenaculum, hank dilators, infraumbilical incision, vicryl endoloop, salpingectomy, dilatation, hemostasis, cervical, laparoscopic, endoloop, sterilization,

The situation described involves a surgical procedure for sterilization, specifically a laparoscopic bilateral partial salpingectomy with cervical dilatation. Although this is a common elective surgery with generally low risk when performed by experienced practitioners, it involves general anesthesia and irreversible changes to the patient's reproductive system, making it somewhat high-stakes. The operation is without complications and was performed successfully, but surgeries always carry inherent risks such as infection, excessive bleeding, or adverse reactions to anesthesia. Additionally, the patient's desire for permanent sterilization indicates a high personal significance. However, from a clinical perspective, the stakes are moderate given the routine nature of the procedure.


Medical Specialty: Consult - History and Phy.
Sample Name: Gen Med Consult - 16

CHIEF COMPLAINT:,  Here with a concern of possibly issues of short-term memory loss.  She is under exceeding amount of stress over the last 5 to 10 years.  She has been a widow over the last 11 years.  Her husband died in an MVA from a drunk driver accident.  She had previously worked at the bank in Conway Springs in Norwich and had several other jobs related to accounting or management services.  She does have an MBA in business.  Currently, she works at T-Mobile Customer Service, and there is quite a bit of technical knowledge, deadlines, and stress related to that job as well.  She feels she has trouble at times absorbing all that she needs to learn as far as the computer skills, protocols, customer service issues, etc.  She describes the job is very demanding and high stress.  She denies any history of weakness, lethargy, or dizziness.  No history of stroke.,CURRENT MEDICATIONS:,  Vioxx 25 mg daily, HCTZ 25 mg one-half tablet daily, Zoloft 100 mg daily, Zyrtec 10 mg daily.,ALLERGIES TO MEDICATIONS: , Naprosyn.,SOCIAL HISTORY, FAMILY HISTORY, PAST MEDICAL HISTORY AND SURGICAL HISTORY: , She has had hypertension very well controlled and history of elevated triglycerides.  She has otherwise been generally healthy.  Nonsmoker.  Please see notes dated 06/28/2004.,REVIEW OF SYSTEMS:,  Review of systems is otherwise negative.,PHYSICAL EXAMINATION:,Vital Signs:  Age:  60.  Weight:  192 pounds.  Blood pressure:  134/80.  Temperature:  97.8 degrees.,General:  A very pleasant 60-year-old white female in no acute distress.  Alert, ambulatory and nonlethargic.,HEENT:  PERRLA.  EOMs are intact.  TMs are clear bilaterally.  Throat is clear.,Neck:  Supple.  No cervical adenopathy.,Lungs:  Clear without wheezes or rales.,Heart:  Regular rate and rhythm.,Abdomen:  Soft nontender to palpation.,Extremities:  Moving all extremities well.,IMPRESSION:,1.  Short-term memory loss, probable situational.,2.  Anxiety stress issues.,PLAN:,  Thirty-minute face-to-face appointment in counseling with the patient.  At length discussion on her numerous stress issues which can certainly cause a loss of concentration and inability to learn.  The current job she is at does sound extremely stressful and demanding.  I think her stress reactions to these as far as feeling frustrated are within normal limits.  We did complete a mini mental state exam including clock drawing, sentence writing, signature, etc.  She does score a maximum score of 30/30 and all other tasks were completed without difficulty or any hesitation.  I did spend quite a bit of time reassuring her as well.  She is currently on Zoloft 100 mg which I think is an appropriate dose.  We will have her continue on that.  She did verbalize understanding and that she actually felt better after our discussion concerning these issues.  At some point in time; however, I would possibly recommend job change if this one would persist as far as the stress levels.  She is going to think about that.
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DESCRIPTION: Short-term memory loss (probable situational) and anxiety stress issues.

consult - history and phy., short-term memory loss, anxiety, short term memory loss, memory loss, stress issues, situational, memory, stress,

The situation involves a patient experiencing stress-related short-term memory loss and anxiety, which are significant health concerns but not immediately life-threatening. The consultation includes a detailed examination and counseling, and the patient is showing signs of improvement after the discussion. There is no acute medical emergency, and the symptoms are attributed to stress, which can potentially be managed with lifestyle changes and counseling. The mention of possibly recommending a job change suggests concern for long-term wellbeing rather than immediate medical intervention.


Medical Specialty: Consult - History and Phy.
Sample Name: Pain from Hernia - ER Consult

HISTORY OF PRESENT ILLNESS:  ,This is a 53-year-old man, who presented to emergency room with multiple complaints including pain from his hernia, some question of blood in his stool, nausea, and vomiting, and also left lower extremity pain.  At the time of my exam, he states that his left lower extremity pain has improved considerably.  He apparently had more significant paresthesias in the past and now he feels that the paresthesias have improved considerably.  He does have a history of multiple medical problems including atrial fibrillation, he is on Coumadin, which is currently subtherapeutic, multiple CVAs in the past, peripheral vascular disease, and congestive heart failure.  He has multiple chronic history of previous ischemia of his large bowel in the past.,PHYSICAL EXAM,VITAL SIGNS:  Currently his temperature is 98.2, pulse is 95, and blood pressure is 138/98.,HEENT:  Unremarkable.,LUNGS:  Clear.,CARDIOVASCULAR:  An irregular rhythm.,ABDOMEN:  Soft.,EXTREMITIES:  His upper extremities are well perfused.  He has palpable radial and femoral pulses.  He does not have any palpable pedal pulses in either right or left lower extremity.  He does have reasonable capillary refill in both feet.  He has about one second capillary refill on both the right hand and left lower extremities and his left foot is perhaps little cool, but it is relatively warm.  Apparently, this was lot worst few hours ago.  He describes significant pain and pallor, which he feels has improved and certainly clinically at this point does not appear to be as significant.,IMPRESSION AND PLAN: , This gentleman with a history of multiple comorbidities as detailed above had what sounds clinically like acute exacerbation of chronic peripheral vascular disease, essentially related to spasm versus a small clot, which may have been lysed to some extent.  He currently has a viable extremity and viable foot, but certainly has significant making compromised flow.  It is unclear to me whether this is chronic or acute, and whether he is a candidate for any type of intervention.  He certainly would benefit from an angiogram to better to define his anatomy and anticoagulation in the meantime.  Given his potential history of recent lower GI bleeding, he has been evaluated by GI to see whether or not he is a candidate for heparinization.  We will order an angiogram for the next few hours and followup on those results to better define his anatomy and to determine whether or not if any interventions are appropriate.  Again, at this point, he has no pain, relatively rapid capillary refill, and relatively normal motor function suggesting a viable extremity.  We will follow him along closely.
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DESCRIPTION: This is a 53-year-old man, who presented to emergency room with multiple complaints including pain from his hernia, some question of blood in his stool, nausea, and vomiting, and also left lower extremity pain.

consult - history and phy., blood in stool, nausea, capillary refill, angiogram, hernia, extremity,

The patient presents with multiple serious medical conditions and symptoms, including a hernia with pain, potential blood in stool, nausea, vomiting, and a history of serious cardiovascular issues like atrial fibrillation, multiple CVAs, congestive heart failure, and peripheral vascular disease. The physical exam notes irregular cardiovascular rhythms, and possible acute exacerbation of chronic peripheral vascular disease. There is also concern about compromised blood flow to the extremities, which requires immediate diagnostic action through an angiogram to assess for potential interventions. Considering his complex medical history, and the current symptoms that could indicate significant vascular issues, this situation is high-stakes, especially as it may impact the patient's viability of extremity and overall health.


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

SUBJECTIVE:,  The patient states that he feels sick and weak.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Highest temperature recorded over the past 24 hours was 101.1, and current temperature is 99.2.,GENERAL:  The patient looks tired.,HEENT:  Oral mucosa is dry.,CHEST:  Clear to auscultation.  He states that he has a mild cough, not productive.,CARDIOVASCULAR:  First and second heart sounds were heard.  No murmur was appreciated.,ABDOMEN:  Soft and nontender.  Bowel sounds are positive. Murphy's sign is negative.,EXTREMITIES:  There is no swelling.,NEURO:  The patient is alert and oriented x 3.  Examination is nonfocal.,LABORATORY DATA: , White count is normal at 6.8, hemoglobin is 15.8, and platelets 257,000.  Glucose is in the low 100s.  Comprehensive metabolic panel is unremarkable.  UA is negative for infection.,ASSESSMENT AND PLAN:,1.  Fever of undetermined origin, probably viral since white count is normal.  Would continue current antibiotics empirically.,2.  Dehydration.  Hydrate the patient.,3.  Prostatic hypertrophy.  Urologist, Dr. X.,4.  DVT prophylaxis with subcutaneous heparin.
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DESCRIPTION: The patient states that he feels sick and weak.

soap / chart / progress notes, fever, dehydration, prophylaxis, white count is normal, white count, sick, weak, temperature,

The progress note describes a patient with a fever, dehydration, mild symptoms like a dry oral mucosa and a mild cough, but importantly, normal lab results and no serious complications detected during the examination. The conditions noted (fever, mild dehydration, possible viral infection, and chronic hypertrophy) are being managed with a plan in place, including hydration and consultation with a urologist. No immediate life-threatening conditions are noted. Thus, while the patient is experiencing discomfort and requires medical attention, the current information suggests that the situation is not extremely critical.


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

Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Tracheostomy

PREOPERATIVE DIAGNOSES,Airway obstruction secondary to severe subglottic tracheal stenosis with foreign body in the trachea.,POSTOPERATIVE DIAGNOSES,Airway obstruction secondary to severe subglottic tracheal stenosis with foreign body in the trachea.,OPERATION PERFORMED,Neck exploration; tracheostomy; urgent flexible bronchoscopy via tracheostomy site; removal of foreign body, tracheal metallic stent material; dilation distal trachea; placement of #8 Shiley single cannula tracheostomy tube.,INDICATIONS FOR SURGERY,The patient is a 50-year-old white male with history of progressive tracheomalacia treated in the National Tennessee, and several years ago he had a tracheal metallic stent placed with some temporary improvement.  However developed progressive problems and he had two additional stents placed with some initial improvement.  Subsequently, he developed progressive airway obstruction and came into the ABC Hospital critical airway service for further evaluation and was admitted on Month DD, YYYY.  He underwent bronchoscopy by Dr. W and found to have an extensive subglottic upper tracheal and distal tracheal stenosis secondary to metallic stent extensive granulation and inflammatory tissue changes.  The patient had some debridement and then was hospitalized and Laryngology and Thoracic Surgery services were consulted for further management.  Exploration of trachea, removal of foreign body stents constricting his airway, dilation and stabilization of his trachea were offered to the patient.  Nature of the proposed procedure including risks and complications of bleeding, infection, alteration of voice, speech, swallowing, voice changes permanently, possibility of tracheotomy temporarily or permanently to maintain his airway, loss of voice, cardiac risk factors, anesthetic risks, recurrence of problems, upon surgical intervention were all discussed at length.  The patient stated that he understood and wished to proceed.,DESCRIPTION OF PROCEDURE,The patient was taken to the operating room, placed in the supine position.  Following adequate monitoring by Anesthesia Service to maintain sedation, the patient's neck was prepped and draped in the sterile fashion.  The neck was then infiltrated with 1% Xylocaine and 1000 epinephrine.  A collar incision approximately 1 fingerbreadth above the clavicle, this was an outline incision, was carried out.  The skin, subcutaneous tissue, platysma, subplatysmal flaps elevated superiorly and inferiorly.  Strap muscles were separated in the midline, dissection carried down to visceral fascia.  Beneath the strap muscles, there was dense inflammation scarring obscuring palpable landmarks.  There appeared to be significant scarring fusion of soft tissue at the perichondrium and cartilage of the cricoid making the cricoid easily definable.  There was a markedly enlarged thyroid isthmus.  Thyroid isthmus was divided and dense inflammation, attachment of the thyroid isthmus, fusion of the thyroid gland to the capsule to the pretracheal fascia requiring extensive blunt sharp dissection.  Trachea was exposed from the cricoid to the fourth ring which entered down into the chest.  The trachea was incised between the second and third ring inferior limb in the midline and excision of small ridge of cartilage on each side sent for pathologic evaluation.  The tracheal cartilage externally had marked thickening and significant stiffness calcification, and the tracheal wall from the outside of the trachea to the mucosa measured 3 to 4 mm in thickness.  The trachea was entered and visualized with thickening of the mucosa and submucosa was noted.  The patient, however, was able to ventilate at this point a #6 Endo Tube was inserted and general anesthesia administered.  Once the airway was secured, we then proceeded working around the #6 Endo Tube as well as with the tube intake and out to explore the trachea with ridged fiberoptic scopes as well as flexible fiberoptic bronchoscopy to the trach site.  Examination revealed extrusion of metallic fragments from stent and multiple metallic fragments were removed from the stent in the upper trachea.  A careful examination of the subglottic area showed inflamed and thickened mucosa but patent subglottis.  After removal of the stents and granulation tissue, the upper trachea was widely patent.  The mid trachea had some marked narrowing secondary to granulation.  Stent material was removed from this area as well.  In the distal third of the trachea, a third stent was embedded within the mucosa, not encroaching on the lumen without significant obstruction distally and this was not disturbed at this time.  All visible stent material in the upper and mid trachea were removed.  Initial attempt to place a #16 Montgomery T tube showed the distal lumen of the T tube to be too short to stent the granulation narrowing of the trachea at the junction of the anterior two thirds and the distal third.  Also, this was removed and a #8 Shiley single cannula tracheostomy tube was placed after removal of the endotracheal tube.  A good ventilation was confirmed and the position of the tube confirmed it to be at the level just above the metallic stent which was embedded in the mucosa.  The distal trachea and mainstem bronchi were widely patent.  This secured his airway and no further manipulation felt to be needed at this time.  Neck wound was thoroughly irrigated and strap muscles were closed with interrupted 3-0 Vicryl.  The skin laterally to the trach site was closed with running 2-0 Prolene.  Tracheostomy tube was secured with interrupted 2-0 silk sutures and the patient was taken back to the Intensive Care Unit in satisfactory condition.  The patient tolerated the procedure well without complication.
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DESCRIPTION: Neck exploration; tracheostomy; urgent flexible bronchoscopy via tracheostomy site; removal of foreign body, tracheal metallic stent material; dilation distal trachea; placement of #8 Shiley single cannula tracheostomy tube.

cardiovascular / pulmonary, airway, laryngology, shiley, alteration of voice, bronchi, bronchoscopy, cannula, cartilage, cricoid, flexible, foreign body, mainstem, obstruction, perichondrium, stenosis, stent, subglottic, swallowing, trachea, tracheal, tracheal stenosis, tracheostomy, shiley single cannula tracheostomy, shiley single cannula, single cannula tracheostomy, thyroid isthmus, stent material, tracheostomy tube, tube, thyroid,

The situation involves a complex surgical procedure to address a severe airway obstruction due to subglottic tracheal stenosis and foreign body removal, which are critical to the patient's ability to breathe. The procedure itself carries significant risks, such as bleeding, infection, and the potential need for permanent airway management solutions. Given the nature of the patient's condition and the necessity of surgical intervention to prevent further airway compromise, this is a high-stakes scenario.


Medical Specialty: Orthopedic
Sample Name: Facetectomy & Foraminotomy

PREOPERATIVE DIAGNOSES,1.  Neck pain with bilateral upper extremity radiculopathy.,2.  Residual stenosis, C3-C4, C4-C5, C5-C6, and C6-C7 with probable instability.,POSTOPERATIVE DIAGNOSES,1.  Neck pain with bilateral upper extremity radiculopathy.,2.  Residual stenosis, C3-C4, C4-C5, C5-C6, and C6-C7 secondary to facet arthropathy with scar tissue.,3.  No evidence of instability.,OPERATIVE PROCEDURE PERFORMED,1.  Bilateral C3-C4, C4-C5, C5-C6, and C6-C7 medial facetectomy and foraminotomy with technical difficulty.,2.  Total laminectomy C3, C4, C5, and C6.,3.  Excision of scar tissue.,4.  Repair of dural tear with Prolene 6-0 and Tisseel.,FLUIDS:,  1500 cc of crystalloid.,URINE OUTPUT: , 200 cc.,DRAINS: , None.,SPECIMENS: , None.,COMPLICATIONS: , None.,ANESTHESIA:,  General endotracheal anesthesia.,ESTIMATED BLOOD LOSS:,  Less than 250 cc.,INDICATIONS FOR THE OPERATION:  ,This is the case of a very pleasant 41 year-old Caucasian male well known to me from previous anterior cervical discectomy and posterior decompression.  Last surgery consisted of four-level decompression on 08/28/06.  The patient continued to complain of posterior neck pain radiating to both trapezius.  Review of his MRI revealed the presence of what still appeared to be residual lateral recess stenosis.  It also raised the possibility of instability and based on this I recommended decompression and posterolateral spinal instrumention; however, intraoperatively, it appeared like there was no abnormal movement of any of the joint segments; however, there was still residual stenosis since the laminectomy that was done previously was partial.  Based on this, I did total decompression by removing the lamina of C3 through C6 and doing bilateral medial facetectomy and foraminotomy at C3-C4, C4-C5, C5-C6, and C6-C7 with no spinal instrumentation.  Operation and expected outcome risks and benefits were discussed with him prior to the surgery.  Risks include but not exclusive of bleeding and infection.  Infection can be superficial, but may also extend down to the epidural space, which may require return to the operating room and evacuation of the infection.  There is also the risk of bleeding that could be superficial but may also be in the epidural space resulting in compression of spinal cord.  This may result in weakness of all four extremities, numbness of all four extremities, and impairment of bowel and bladder function, which will require an urgent return to the operating room and evacuation of the hematoma.  There is also the risk of a dural tear with its attendant problems of CSF leak, headache, nausea, vomiting, photophobia, pseudomeningocele, and dural meningitis.  This too may require return to the operating room for evacuation of said pseudomeningocele and repair.  The patient understood the risk of the surgery.  I told him there is just a 30% chance that there will be no improvement with the surgery; he understands this and agreed to have the procedure performed.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating room, awake, alert, not in any form of distress.  After smooth induction and intubation, a Foley catheter was inserted.  Monitoring leads were also placed by Premier Neurodiagnostics for both SSEP and EMG monitoring.  The SSEPs were normal, and the EMGs were silent during the entire case.  After completion of the placement of the monitoring leads, the patient was then positioned prone on a Wilson frame with the head supported on a foam facial support.  Shave was then carried out over the occipital and suboccipital region.  All pressure points were padded.  I proceeded to mark the hypertrophic scar for excision.  This was initially cleaned with alcohol and prepped with DuraPrep.,After sterile drapes were laid out, incision was made using a scalpel blade #10.  Wound edge bleeders were carefully controlled with bipolar coagulation and a hot knife was utilized to excise the hypertrophic scar.  Dissection was then carried down to the cervical fascia, and by careful dissection to the scar tissue, the spinous process of C2 was then identified.  There was absence of the spinous process of C3, C4, C5, and C6, but partial laminectomy was noted; removal of only 15% of the lamina.  With this completed, we proceeded to do a total laminectomy at C3, C4, C5, and C6, which was technically difficult due to the previous surgery.  There was also a dural tear on the right C3-C4 space that was exposed and repaired with Prolene 6-0 and later with Tisseel.  By careful dissection and the use of a -5 and 3 mm bur, total laminectomy was done as stated with bilateral medial facetectomy and foraminotomy done at C3-C4, C4-C5, C5-C6, and C6-C7.  There was significant epidural bleeding, which was carefully coagulated.  At two points, I had to pack this with small pieces of Gelfoam.  After repair of the dural tear, Valsalva maneuver showed no evidence of any CSF leakage.  Area was irrigated with saline and bacitracin and then lined with Tisseel.  The wound was then closed in layers with Vicryl 0 simple interrupted sutures to the fascia; Vicryl 2-0 inverted interrupted sutures to the dermis and a running nylon 2-0 continuous vertical mattress stitch.  The patient was extubated and transferred to recovery.
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DESCRIPTION: Bilateral C3-C4, C4-C5, C5-C6, and C6-C7 medial facetectomy and foraminotomy with technical difficulty, total laminectomy C3, C4, C5, and C6, excision of scar tissue, and repair of dural tear with Prolene 6-0 and Tisseel.

The described procedure involves an invasive spinal surgery addressing complex cervical spine conditions (neck pain, radiculopathy, and stenosis). It includes medial facetectomies, foraminotomies, total laminectomies, and the repair of a dural tear, all of which carry significant risks. Such surgeries are high-stakes due to the proximity to the spinal cord and the potential for serious complications including infection, bleeding, nerve damage, or paralysis. Despite the controlled environment and absence of intraoperative complications, the inherent risks and the severity of issues addressed make this situation high-stakes.


Medical Specialty: Surgery
Sample Name: Port-A-Cath Insertion - 5

PROCEDURES PERFORMED,1.  Insertion of subclavian dual-port Port-A-Cath.,2.  Surgeon-interpreted fluoroscopy.,OPERATIVE PROCEDURE IN DETAIL: , After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, patient was taken to the operating room and general endotracheal anesthesia was administered.  Next, the chest was prepped and draped in a standard surgical fashion.  A #18-gauge spinal needle was used to aspirate blood from the subclavian vein.  After aspiration of venous blood, Seldinger technique was used to thread a J wire.  The distal tip of the J wire was confirmed to be in adequate position with surgeon-interpreted fluoroscopy.  Next a #15-blade scalpel was used to make an incision in the skin.  Dissection was carried down to the level of the pectoralis muscle.  A pocket was created.  A dual-port Port-A-Cath was lowered into the pocket and secured with #2-0 Prolene.  Both ports were flushed.  The distal tip was pulled through to the wire exit site with a Kelly clamp.  It was cut to the appropriate length.  Next a dilator and sheath were threaded over the J wire.  The J wire and dilator were removed, and the distal tip of the dual-port Port-A-Cath was threaded over the sheath, which was simultaneously withdrawn.  Both ports of the dual-port Port-A-Cath were flushed and aspirated without difficulty.  The distal tip was confirmed to be in adequate position with surgeon-interpreted fluoroscopy.  The wire access site was closed with a 4-0 Monocryl.  The port pocket was closed in 2 layers with 2-0 Vicryl followed by 4-0 Monocryl in a running subcuticular fashion.  Sterile dressing was applied.  The patient tolerated the procedure well and was transferred to the PACU in good condition
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DESCRIPTION: Insertion of subclavian dual-port Port-A-Cath and surgeon-interpreted fluoroscopy.

surgery, surgeon-interpreted fluoroscopy, j wire, dual-port port-a-cath, port a cath, subclavian, fluoroscopy, cathNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.

The situation involves a surgical procedure for the insertion of a Port-A-Cath, which is used for long-term intravenous access typically in patients undergoing chemotherapy or other treatments. The procedure is invasive, requires general anesthesia, and involves the use of fluoroscopy for accurate placement. The risks of surgery, potential complications, and the need for accurate placement make it moderately high-stakes for the patient and medical team. However, it is a routine elective procedure, not an emergency, which slightly lowers the stakes compared to emergency surgeries.


Medical Specialty: Consult - History and Phy.
Sample Name: Consult - Palpitations & Presyncope

HISTORY OF PRESENT ILLNESS: , The patient is a charming and delightful 46-year-old woman admitted with palpitations and presyncope.,The patient is active and a previously healthy young woman, who has had nine years of occasional palpitations.  Symptoms occur three to four times per year and follow no identifiable pattern.  She has put thought and effort in trying to identify precipitating factors or circumstances but has been unable to do so.  Symptoms can last for an hour or more and she feels as if her heart is going very rapidly but has never measured her heart rate.  The last two episodes, the most recent of which was yesterday, were associated with feeling of darkness descending as if a shade was being pulled down in front of her vision.  On neither occasion did she lose consciousness.,Yesterday, she had a modestly active morning taking a walk with her dogs and performing her normal routines.  While working on a computer, she had a spell.  Palpitations persisted for a short time thereafter as outlined in the hospital's admission note prompting her to seek evaluation at the hospital.  She was in sinus rhythm on arrival and has been asymptomatic since.,No history of exogenous substance abuse, alcohol abuse, or caffeine abuse.  She does have a couple of sodas and at least one to two coffees daily.  She is a nonsmoker.  She is a mother of two.  There is no family history of congenital heart disease.  She has had no history of thoracic trauma.  No symptoms to suggest thyroid disease.,No known history of diabetes, hypertension, or dyslipidemia.  Family history is negative for ischemic heart disease.,Remote history is significant for an ACL repair, complicated by contact urticaria from a neoprene cast.,No regular medications prior to admission.,The only allergy is the neoprene reaction outlined above.,PHYSICAL EXAMINATION: , Vital signs as charted.  Pupils are reactive.  Sclerae nonicteric.  Mucous membranes are moist.  Neck veins not distended.  No bruits.  Lungs are clear.  Cardiac exam is regular without murmurs, gallops, or rubs.  Abdomen is soft without guarding, rebound masses, or bruits.  Extremities well perfused.  No edema.  Strong and symmetrical distal pulses.,A 12-lead EKG shows sinus rhythm with normal axis and intervals.  No evidence of preexcitation.,LABORATORY STUDIES: , Unremarkable.  No evidence of myocardial injury.  Thyroid function is pending.,Two-dimensional echocardiogram shows no evidence of clinically significant structural or functional heart disease.,IMPRESSION/PLAN: , Episodic palpitations over a nine-year period.  Outpatient workup would be appropriate.  Event recorder should be obtained and the patient can be seen again in the office upon completion of that study.  Suppressive medication (beta-blocker or Cardizem) was discussed with the patient for symptomatic improvement, though this would be unlikely to be a curative therapy.  The patient expresses a preference to avoid medical therapy if possible.,Thank you for this consultation.  We will be happy to follow her both during this hospitalization and following discharge.  Caffeine avoidance was discussed as well.,ADDENDUM: , During her initial evaluation, a D-dimer was mildly elevated to 5.  CT scan showed no evidence of pulmonary embolus.  Lower extremity venous ultrasound is pending; however, in the absence of embolization to the pulmonary vasculature, this would be an unlikely cause of palpitations.  In addition, no progression over the nine-year period that she has been symptomatic suggests that this is an unlikely cause.,
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DESCRIPTION: The patient admitted with palpitations and presyncope.

consult - history and phy., presyncope, palpitations, episodic palpitations, beta-blocker, ultrasound, palpitations and presyncope, sinus rhythm, heart disease, heart

The situation involves a medical evaluation of a patient's palpitations and presyncope, symptoms that could be indicative of various cardiovascular issues. Although the patient's symptoms have persisted for nine years without significant progression or severity, and tests have not shown urgent life-threatening conditions, they necessitate thorough investigation to rule out any potentially serious underlying causes. The patient's current situation does not involve immediate life-threatening conditions as she is currently asymptomatic, but the nature of her symptoms warrants an outpatient workup with monitoring. Therefore, the situation is somewhat high-stakes due to the potential implications on the patient’s health if left unchecked, but not critically urgent at the moment.


Medical Specialty: Surgery
Sample Name: Knee Arthroscopy & Medial Meniscoplasty

PREOPERATIVE DIAGNOSIS: , Internal derangement, left knee.,POSTOPERATIVE DIAGNOSIS: , Internal derangement, left knee.,PROCEDURE PERFORMED:,  Arthroscopy of the left knee with medial meniscoplasty.,ANESTHESIA:  ,LMA.,GROSS FINDINGS: , Displaced bucket-handle tear of medial meniscus, left knee.,PROCEDURE: , After informed consent was obtained, the patient was taken to ABCD General Hospital Operating Room #1 where anesthesia was administered by the Department of Anesthesiology.  The patient was then transferred to the operating room table in supine position with Johnson knee holder well-padded.  Tourniquet was placed around the left upper thigh.  The limb was then prepped and draped in usual sterile fashion.  Standard anteromedial and anterolateral arthroscopy portals were obtained and a systematic examination of the knee was then performed.  Patellofemoral joint showed frequent chondromalacia.  Examination of the medial compartment showed a displaced bucket-handle tear of the medial meniscus involving the entire posterior, parietal, and portion of his anterior portion of the medial meniscus.  The medial femoral condyle and medial tibial plateau were unaffected.  Intercondylar notch examination revealed an intact ACL and PCL stable to drawer testing and probing and the lateral compartment showed an intact lateral meniscus.  The femoral condyle and tibial plateau were all stable to probing.  Attention was then directed back to the medial compartment where the detached portion of the meniscus was excised using arthroscopy scissors.  A shaver was then used to smooth all the edges until the margins were stable to probing.,The knee was then flushed with normal saline and suctioned dry.  20 cc of 0.25% Marcaine was injected into the knee and into the arthroscopy portals.  A dressing consisting of Adaptic, 4x4s, ABDs, and Webril were applied followed by a TED hose.  The patient was then transferred to the recovery room in stable condition.
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DESCRIPTION: Arthroscopy of the left knee with medial meniscoplasty.  Internal derangement, left knee. Displaced bucket-handle tear of medial meniscus, left knee.

surgery, arthroscopy, meniscoplasty, derangement, internal derangement, knee, displaced bucket handle tear, femoral condyle, tibial plateau, medial meniscoplasty, medial meniscus, medial

The scenario describes a surgical procedure for a knee condition, specifically an arthroscopy with medial meniscoplasty to address a displaced bucket-handle tear of the medial meniscus. Surgical procedures generally carry inherent risks, such as infection, complications from anesthesia, or improper healing, which can significantly impact the patient's health and quality of life if not performed correctly. Therefore, this is considered a medically significant procedure with important health implications.