Medical Specialty: Surgery
Sample Name: OssaTron Extracorporeal Shockwave Therapy

PREOPERATIVE DIAGNOSIS:,  Right lateral epicondylitis.,POSTOPERATIVE DIAGNOSIS:,  Right lateral epicondylitis.,OPERATION PERFORMED:,  OssaTron extracorporeal shockwave therapy to right lateral epicondyle.,ANESTHESIA:,  Bier block.,DESCRIPTION OF PROCEDURE: , With the patient under adequate Bier block anesthesia, the patient was positioned for extracorporeal shockwave therapy.  The OssaTron equipment was brought into the field and the nose piece for treatment was placed against the lateral epicondyle targeting the area previously determined with the patient's input of maximum pain.  Then using standard extracorporeal shockwave protocol, the OssaTron treatment was applied to the lateral epicondyle of the elbow.  After completion of the treatment, the tourniquet was deflated, and the patient was returned to the holding area in satisfactory condition having tolerated the procedure well.
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DESCRIPTION: OssaTron extracorporeal shockwave therapy to right lateral epicondyle.  Right lateral epicondylitis.

surgery, epicondylitis, ossatron extracorporeal shockwave therapy, bier block, epicondyle, ossatron, extracorporeal, shockwave,

The procedure described is a non-invasive treatment for right lateral epicondylitis, commonly known as tennis elbow. It involves the use of extracorporeal shockwave therapy, which is generally considered a low-risk procedure. The use of Bier block anesthesia adds some complexity but is typically well-managed in a surgical setting. The post-procedure note indicates the patient tolerated the procedure well, with no complications reported. While all medical procedures carry some level of risk, this particular procedure does not involve life-threatening risks or high-level surgical interventions. Therefore, the situation is not high-stakes in nature.


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

Medical Specialty: Surgery
Sample Name: Low-Transverse C-Section - 10

PREOPERATIVE DIAGNOSES:,1.  36th and 4/7th week, intrauterine growth rate.,2.  Charcot-Marie-Tooth disease.,3.  Previous amniocentesis showing positive fetal lung maturity, family planning complete.,4.  Previous spinal fusion.,5.  Two previous C-sections.  The patient refuses trial labor.  The patient is with regular contractions dilated to 3, possibly an early labor, contractions are getting more and more painful.,POSTOPERATIVE DIAGNOSES:,1.  36th and 4/7th week, intrauterine growth rate.,2.  Charcot-Marie-Tooth disease.,3.  Previous amniocentesis showing positive fetal lung maturity, family planning complete.,4.  Previous spinal effusion.,5.  Two previous C-section.  The patient refuses trial labor.  The patient is with regular contractions dilated to 3, possibly an early labor, contractions are getting more and more painful.,6.  Adhesions of bladder.,7.  Poor fascia quality.,8.  Delivery of a viable female neonate.,PROCEDURE PERFORMED:,1.  A repeat low transverse cervical cesarean section.,2.  Lysis of adhesions.,3.  Dissection of the bladder of the anterior abdominal wall and away from the fascia.,4.  The patient also underwent a bilateral tubal occlusion via Hulka clips.,COMPLICATIONS: , None.,BLOOD LOSS:,  600 cc.,HISTORY AND INDICATIONS:  ,Indigo Carmine dye bladder test in which the bladder was filled, showed that there was no defects in the bladder of the uterus.  The uterus appeared to be intact.  This patient is a 26-year-old Caucasian female.  The patient is well known to the OB/GYN clinic.  The patient had two previous C-sections.  She appears to be in probably early labor.  She had an amniocentesis early today.  She is contracting regularly about every three minutes.  The contractions are painful and getting much more so since the amniocentesis.  The patient had fetal lung maturity noted.  The patient also has probable IUGR as none of her babies have been over 4 lb.  The patient's baby appears to be somewhat small.  The patient suffers from Charcot-Marie-Tooth disease, which has left her wheelchair bound.  The patient has had a spinal fusion, however, family planning is definitely complete per the patient.  The patient refuses trial labor.  The patient and I discussed the consent.  She understands the foreseeable risks and complications, alternative treatment of the procedure itself, and recovery.  Her questions were answered.  The patient also understands that when we occlude her tube that she is at risk for failure of this part of the procedure, which would result in either an intrauterine or ectopic pregnancy.  The patient understands this and would like to try our best.,PROCEDURE:  ,The patient was taken back to the operative suite.  She was given general anesthetic by Department of Anesthesiology.  Once again, in layman's terms, the patient understands the risks.  The patient had the informed consent reviewed and understood.  The patient has had a Pfannenstiel incision, which was slightly bent towards the right side favoring the right side.  The patient had the first knife went through this incision.  The second knife was used to go to the level of fascia.  The fascia was very thin, ruddy in appearance, and with abundant scar tissue.  The fascia was incised.  Following this, we were able to see the peritoneum.  There was really no obvious rectus abdominal muscles noted.  They were very weak, atrophic, and thin.  The patient has the peritoneum tented up.  We entered the abdominal cavity.  The bladder flap was then entered into the anterior abdominal wall and to the underlying area of the fascia.  The bladder flap was then entered into the uterus as well.  There are some bladder adhesions.  We removed these adhesions and we removed the bladder of the fascia.  We dissected the bladder of the lower segment.  We made a small nick on the lower segment.  We were able to utilize the blunt end of the knife to enter into the uterine cavity.  The baby was in occiput transverse position with the ear being cocked at such a position as well.  The patient's baby was delivered without difficulty.  It was a 4 lb and 10 oz baby girl who vigorously cried well.  There was a prolapse of the umbilical cord just below the chin as well and this may be attributed to the decelerations we caught on the monitor strip right before we decided to have her undergo resection.  The patient's placenta was delivered.  There was no retained placenta.  The uterine incision was closed with two layers of #0 Vicryl, the second layer imbricating over the first.  The patient on the right side had the inferior epigastric artery and the vein just underneath the peritoneum easily visualized.  Then we ligated this as there was bleeding and oozing.  The patient had the Indigo Carmine instilled into the bladder with some saline about 300 cc.  The 400 cc was instilled.  The bladder appears to be intact.  The bladder did require extensive dissection of the fascia in order to be able to get a proper fascial edges for closure and dissection of the lower uterine segment.  There was some oozing around the area of the bladder.  We placed an Avitene there.  The two Hulka clips were placed perpendicular to going across each fallopian tube into the mesosalpinx.  The patient has two clips on each side.  There was excellent tubal occlusion and placement.  The uterus was placed back into the abdominal cavity.  We rechecked again.  The tubal placement was excellent.  It did not involve the round ligaments, uterosacral ligaments, the uteroovarian ligaments, and the tube into the mesosalpinx.  The patient then underwent further examination.  Hemostasis appeared to be good.  The fascia was reapproximated with short running intervals of #0 Vicryl across the fascia.  We took care not to get into any bleeders and to make sure that the fascia was indeed closed as best as it was possible.  The Scarpa's fascia was reapproximated with #0 gut.  The skin was reapproximated then as well via subcutaneous closure.  The patient's sponge and needle counts found to be correct.  Uterus appeared to be normal prior to closure.  Bladder appeared to be normal.  The patient's blood loss is 600 cc.
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DESCRIPTION: A repeat low transverse cervical cesarean section, Lysis of adhesions, Dissection of the bladder of the anterior abdominal wall and away from the fascia, and the patient also underwent a bilateral tubal occlusion via Hulka clips.

surgery, intrauterine growth rate, charcot-marie-tooth disease, amniocentesis, c-sections, trial labor, low transverse cervical cesarean section, lysis of adhesions, dissection, bladder, abdominal wall, fascia, hulka clips, bilateral tubal occlusion, intrauterine, transverse, uterus, abdominal,

The situation involves a surgical procedure for a patient with a complex medical history including previous C-sections, Charcot-Marie-Tooth disease, and spinal fusion. The surgery itself involves multiple procedures including a repeat C-section, bladder dissection, and tubal occlusion. The presence of conditions like Charcot-Marie-Tooth disease, past surgeries, and current active labor increase the complexity and potential risk of complications. Although the procedure completed successfully without immediate complications, the stakes remain high due to the potential for future complications and the irreversible nature of some aspects of the surgery, such as the tubal occlusion with intention for sterilization. There is also inherent high-stakes involvement given that this is an obstetric procedure where both maternal and fetal health are critical considerations.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Posttransplant Lymphoproliferative Disorder

CHIEF COMPLAINT: , The patient is here for followup visit and chemotherapy.,DIAGNOSES:,1.  Posttransplant lymphoproliferative disorder.,2.  Chronic renal insufficiency.,3.  Squamous cell carcinoma of the skin.,4.  Anemia secondary to chronic renal insufficiency and chemotherapy.,5.  Hypertension.,HISTORY OF PRESENT ILLNESS: , A 51-year-old white male diagnosed with PTLD in latter half of 2007.  He presented with symptoms of increasing adenopathy, abdominal pain, weight loss, and anorexia.  He did not seek medical attention immediately.  He was finally hospitalized by the renal transplant service and underwent a lymph node biopsy in the groin, which showed diagnosis of large cell lymphoma.  He was discussed at the hematopathology conference.  Chemotherapy with rituximab plus cyclophosphamide, daunorubicin, vincristine, and prednisone was started.  First cycle of chemotherapy was complicated by sepsis despite growth factor support.  He also appeared to have become disoriented either secondary to sepsis or steroid therapy.,The patient has received 5 cycles of chemotherapy to date.  He did not keep his appointment for a PET scan after 3 cycles because he was not feeling well.  His therapy has been interrupted for infection related to squamous cell cancer, skin surgery as well as complaints of chest infection.,The patient is here for the sixth and final cycle of chemotherapy.  He states he feels well.  He denies any nausea, vomiting, cough, shortness of breath, chest pain or fatigue.  He denies any tingling or numbness in his fingers.  Review of systems is otherwise entirely negative.,Performance status on the ECOG scale is 1.,PHYSICAL EXAMINATION:,VITAL SIGNS:  He is afebrile.  Blood pressure 161/80, pulse 65, weight 71.5 kg, which is essentially unchanged from his prior visit.  There is mild pallor noted.  There is no icterus, adenopathy or petechiae noted.  CHEST:  Clear to auscultation.  CARDIOVASCULAR:  S1 and S2 normal with regular rate and rhythm.  Systolic flow murmur is best heard in the pulmonary area.  ABDOMEN:  Soft and nontender with no organomegaly.  Renal transplant is noted in the right lower quadrant with a scar present.  EXTREMITIES:  Reveal no edema.,LABORATORY DATA: , CBC from today shows white count of 9.6 with a normal differential, ANC of 7400, hemoglobin 8.9, hematocrit 26.5 with an MCV of 109, and platelet count of 220,000.,ASSESSMENT AND PLAN:,1.  Diffuse large B-cell lymphoma following transplantation.  The patient is to receive his sixth and final cycle of chemotherapy today.  PET scan has been ordered to be done within 2 weeks.  He will see me back for the visit in 3 weeks with CBC, CMP, and LDH.,2.  Chronic renal insufficiency.,3.  Anemia secondary to chronic renal failure and chemotherapy.  He is to continue on his regimen of growth factor support.,4.  Hypertension.  This is elevated today because he held his meds because he is getting rituximab other than that this is well controlled.  His CMP is pending from today.,5.  Squamous cell carcinoma of the skin.  The scalp is well healed.  He still has an open wound on the right posterior aspect of his trunk.  This has no active drainage, but it is yet to heal.  This probably will heal by secondary intention once chemotherapy is finished.  Prescription for prednisone as part of his chemotherapy has been given to him.
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DESCRIPTION: Posttransplant lymphoproliferative disorder, chronic renal insufficiency, squamous cell carcinoma of the skin, anemia secondary to chronic renal insufficiency and chemotherapy, and hypertension.  The patient is here for followup visit and chemotherapy.

soap / chart / progress notes, anemia, chemotherapy, posttransplant lymphoproliferative disorder, squamous cell carcinoma, chronic renal insufficiency, renal insufficiency, adenopathy, lymphoproliferative,

This situation involves a patient with multiple serious medical conditions, including posttransplant lymphoproliferative disorder, chronic renal insufficiency, squamous cell carcinoma, anemia, and hypertension. The patient is receiving chemotherapy, which is inherently a high-stakes treatment due to potential severe side effects and complications, such as the sepsis mentioned in the history. While the patient appears stable at the moment, the ongoing need for chemotherapy and monitoring of multiple health issues contribute to the high-stakes nature of the situation. Decisions made during this followup could significantly impact the patient's health outcomes.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Pleurocentesis

PREOPERATIVE DIAGNOSIS: , Right pleural effusion with respiratory failure and dyspnea.,POSTOPERATIVE DIAGNOSIS: , Right pleural effusion with respiratory failure and dyspnea.,PROCEDURE: , Ultrasound-guided right pleurocentesis.,ANESTHESIA: , Local with lidocaine.,TECHNIQUE IN DETAIL: , After informed consent was obtained from the patient and his mother, the chest was scanned with portable ultrasound.  Findings revealed a normal right hemidiaphragm, a moderate right pleural effusion without septation or debris, and no gliding sign of the lung on the right.  Using sterile technique and with ultrasound as a guide, a pleural catheter was inserted and serosanguinous fluid was withdrawn, a total of 1 L.  The patient tolerated the procedure well.  Portable x-ray is pending.
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DESCRIPTION: Ultrasound-guided right pleurocentesis for right pleural effusion with respiratory failure and dyspnea.

cardiovascular / pulmonary, pleural effusion, dyspnea, gliding sign, hemidiaphragm, pleural catheter, pleurocentesis, respiratory, serosanguinous fluid, ultrasound, pleural,

The situation involves a medical procedure to address a patient's right pleural effusion, which can cause respiratory failure and dyspnea. This condition is serious, as it affects breathing and can lead to further complications if not treated. The procedure, pleurocentesis, however, is relatively routine and was successful, as the patient tolerated it well. Given that medical procedures inherently carry some risk, and the underlying condition (respiratory failure) is serious, this situation is somewhat high-stakes, but not at the highest urgency level since it was routine and completed without issue.


Medical Specialty: Surgery
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 situation described involves a complex surgical procedure with potential risks such as bleeding, infection, and complications from a dural tear that could significantly impact the patient's health. Given the complexity of the surgery, previous surgical history, and potential outcomes -- including risks of serious neurological deficits -- it represents a high-stakes situation. The surgery also involved unexpected technical difficulties, which could increase the stakes due to the potential for complications.


Medical Specialty: Dermatology
Sample Name: Acne - SOAP

SUBJECTIVE:,  The patient is a 49-year-old white female, established patient to Dermatology, last seen in the office on 08/10/2004.  She comes in today for reevaluation of her acne plus she has had what she calls a rash for the past two months now on her chest, stomach, neck, and back.  On examination, this is a flaring of her acne with small folliculitis lesions.  The patient has been taking amoxicillin 500 mg b.i.d. and using Tazorac cream 0.1, and her face is doing well, but she has been out of her medicine now for three days also.  She has also been getting photofacials at Healing Waters and was wondering about what we could offer as far as cosmetic procedures and skin care products, etc.  The patient is married.  She is a secretary.,FAMILY, SOCIAL, AND ALLERGY HISTORY:,  She has hay fever, eczema, sinus, and hives.  She has no melanoma or skin cancers or psoriasis.  Her mother had oral cancer.  The patient is a nonsmoker.  No blood tests.  Had some sunburn in the past.  She is on benzoyl peroxide and Daypro.,CURRENT MEDICATIONS:,  Lexapro, Effexor, Ditropan, aspirin, vitamins.,PHYSICAL EXAMINATION:,  The patient is well developed, appears stated age.  Overall health is good.  She has a couple of acne lesions, one on her face and neck but there are a lot of small folliculitis-like lesions on her abdomen, chest, and back.,IMPRESSION:,  Acne with folliculitis.,TREATMENT:,1.  Discussed condition and treatment with the patient.,2.  Continue the amoxicillin 500 mg two at bedtime.,3.  Add Septra DS every morning with extra water.,4.  Continue the Tazorac cream 0.1; it is okay to use on back and chest also.,5.  Referred to ABC clinic for an aesthetic consult.  Return in two months for followup evaluation of her acne.
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DESCRIPTION: Acne with folliculitis.

Acne with folliculitis.

dermatology, acne with folliculitis, tazorac cream, acne, tazorac, cream, folliculitis,

The situation describes a dermatology case focusing on acne with folliculitis. While the patient is experiencing discomfort and is seeking further cosmetic and skin care options, the condition itself is not life-threatening. The treatment plan is standard and involves continuing antibiotics, topical treatment, and referral for cosmetic consultation. Given the patient's overall good health and the non-critical nature of acne and folliculitis, the stakes are not considered high.


Medical Specialty: Surgery
Sample Name: Laparoscopic Orchiopexy

PREOPERATIVE DIAGNOSIS: , Bilateral undescended testes.,POSTOPERATIVE DIAGNOSIS: , Bilateral undescended testes, bilateral intraabdominal testes.,PROCEDURE: , Examination under anesthesia and laparoscopic right orchiopexy.,ESTIMATED BLOOD LOSS:,  Less than 5 mL.,FLUIDS RECEIVED:  ,110 mL of crystalloid.,INTRAOPERATIVE FINDINGS: , Atrophic bilateral testes, right is larger than left.  The left had atrophic or dysplastic vas and epididymis.,TUBES AND DRAINS: , No tubes or drains were used.,INDICATIONS FOR OPERATION:  ,The patient is a 7-1/2-month-old boy with bilateral nonpalpable testes.  Plan is for exploration, possible orchiopexy.,DESCRIPTION OF OPERATION:  ,The patient was taken to the operating room where surgical consent, operative site, and patient identification were verified.  Once he was anesthetized, he was then palpated and again both testes were nonpalpable.  Because of this, a laparoscopic approach was then elected.  We then sterilely prepped and draped the patient, put an 8-French feeding tube in the urethra, attached to bulb grenade for drainage.  We then made an infraumbilical incision with a 15-blade knife and then further extended with electrocautery and with curved mosquito clamps down to the rectus fascia where we made stay sutures of 3-0 Monocryl on the anterior and posterior sheaths and then opened up the fascia with the curved Metzenbaum scissors.  Once we got into the peritoneum, we placed a 5-mm port with 0-degree short lens.  Insufflation was then done with carbon dioxide up to 10 to 12 mmHg.  We then evaluated.  There was no bleeding noted.  He had a closed ring on the left with a small testis that was evaluated and found to have short vessels as well as atrophic or dysplastic vas, which was barely visualized.  The right side was also intraabdominal, but slightly larger, had better vessels, had much more recognizable vas, and it was closer to the internal ring.  So, we elected to do an orchiopexy on the right side.  Using the laparoscopic 3- and 5-mm dissecting scissors, we then opened up the window at the internal ring through the peritoneal tissue, then dissected it medially and laterally along the line of the vas and along the line of the vessels up towards the kidney, mid way up the abdomen, and across towards the bladder for the vas.  We then used the Maryland dissector to gently tease this tissue once it was incised.  The gubernaculum was then divided with electrocautery and the laparoscopic scissors.  We were able to dissect with the hook dissector in addition to the scissors the peritoneal shunts with the vessels and the vas to the point where we could actually stretch and bring the testis across to the other side, left side of the ring.  We then made a curvilinear incision on the upper aspect of the scrotum on the right with a 15-blade knife and extended down the subcutaneous tissue with electrocautery.  We used the curved tenotomy scissors to make a subdartos pouch.  Using a mosquito clamp, we were able to go in through the previous internal ring opening, grasped the testis, and then pulled it through in a proper orientation.  Using the hook electrode, we were able to dissect some more of the internal ring tissue to relax the vessels and the vas, so there was no much traction.  Using 2 stay sutures of 4-0 chromic, we tacked the testis to the base of scrotum into the middle portion of the testis.  We then closed the upper aspect of the subdartos pouch with a 4-0 chromic and then closed the subdartos pouch and the skin with subcutaneous 4-0 chromic.  We again evaluated the left side and found again that the vessels were quite short.  The testis was more atrophic, and the vas was virtually nonexistent.  We will go back at a later date to try to bring this down, but it will be quite difficult and has a higher risk for atrophy because of the tissue that is present.  We then removed the ports, closed the fascial defects with figure-of-eight suture of 3-0 Monocryl, closed the infraumbilical incision with two Monocryl stay sutures to close the fascial sheath, and then used 4-0 Rapide to close the skin defects, and then using Dermabond tissue adhesives, we covered all incisions.  At the end of the procedure, the right testis was well descended within the scrotum, and the feeding tube was removed.  The patient had IV Toradol and was in stable condition upon transfer to recovery room.
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DESCRIPTION: Examination under anesthesia and laparoscopic right orchiopexy.

surgery, laparoscopic right orchiopexy, undescended testes, orchiopexy, bilateral undescended testes, mosquito clamps, subdartos pouch, internal ring, laparoscopic,

The procedure described is a laparoscopic orchiopexy for a 7.5-month-old child with bilateral undescended testes. Although the procedure itself is common and typically has a good prognosis, it involves general anesthesia and surgical intervention, which always carry some risk, especially in very young patients. Additionally, the situation is complicated by the condition of the left testis, which is atrophic and poses a higher risk for future intervention, potentially affecting fertility and hormonal function. The stakes are significant because they concern the child's reproductive and hormonal health, but it is not life-threatening. Therefore, the importance is recognized though not as critical as a life-saving procedure.


Medical Specialty: Neurology
Sample Name: MCA Aneurysm

HX: ,This 46y/o RHM with HTN was well until 2 weeks prior to exam when he experienced sudden onset dizziness and RUE clumsiness. The symptoms resolved within 10 min. He did well until the afternoon of admission when while moving the lawn he experienced lightheadedness, RUE dysfunction and expressive aphasia (could not get the words out). His wife took him to his local MD, and on the way there his symptoms resolved. His aphasia recurred at his physician's office and a CT scan of the brain revealed a left temporal mass. He was transferred to UIHC.,PMH:, HTN for many years,MEDS:, Vasotec and Dyazide,SHX/FHX:, ETOH abuse (quit '92), 30pk-yr Cigarettes (quit '92),EXAM:, BP158/92, HR91, RR16,MS: Speech fluent without dysarthria,CN: no deficits noted,Motor: no weakness or abnormal tone noted,Sensory: no deficits noted,Coord: normal,Station: no drift,Gait ND,Reflexes: 3+ throughout. Plantars down-going bilaterally.,Gen exam: unremarkable,STUDIES:, WBC14.3K, Na 132, Cl 94, CO2 22, Glucose 129.,CT Brain without contrast: Calcified 2.5 x 2.5cm mass arising from left sylvian fissure/temporal lobe.,MRI Brain, 8/31/92: right temporo-parietal mass with mixed signal on T1 and T2 images. It has a peripheral dark rim on T1 and T2 with surrounding edema. This suggests a component of methemoglobin and hemosiderin within it. Slight peripheral enhancement was identified. There are two smaller foci of enhancement in the posterior parietal lobe on the right. There is nonspecific white matter foci within the pons and right thalamus. Impression: right temporoparietal hemorrhage, suggesting aneurysm or mass. The two smaller foci may suggest metastasis. The white matter changes probably reflect microvascular disease.,3 Vessel cerebroangiogram, 8/31/92: Lobulated fusiform aneurysm off a peripheral branch of the left middle cerebral artery with slow flow into the vessel distal to the aneurysm.,COURSE:, The aneurysm was felt to be inoperable and he was discharged home on Dilantin, ASA, and Diltiazem.
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DESCRIPTION: Patient with sudden onset dizziness and RUE clumsiness.  Giant Left MCA Aneurysm.

neurology, mca aneurysm, rue clumsiness, white matter, aneurysm, mca, dizziness, aphasia, matter, clumsiness, brain, peripheral,

The situation involves a 46-year-old male patient with a giant left MCA (Middle Cerebral Artery) aneurysm, indicated by neurological symptoms such as sudden dizziness, right upper extremity clumsiness, and expressive aphasia. This condition is high-stakes because an MCA aneurysm poses a significant risk for subarachnoid hemorrhage or stroke, which can lead to severe neurological damage or death. Despite being inoperable, the aneurysm presents a substantial ongoing risk that must be managed carefully with medication and monitoring, highlighting the critical nature of this medical scenario.


Medical Specialty: Dentistry
Sample Name: Bony Impacted Teeth Removal

PREOPERATIVE DIAGNOSIS:,  Completely bony impacted teeth #1, #16, #17, and #32.,POSTOPERATIVE DIAGNOSIS: , Completely bony impacted teeth #1, #16, #17, and #32.,PROCEDURE: , Surgical removal of completely bony impacted teeth #1, #16, #17, and #32.,ANESTHESIA: , General nasotracheal.,COMPLICATIONS: , None.,CONDITION:  ,Stable to PACU.,DESCRIPTION OF PROCEDURE: , Patient was brought to the operating room, placed on the table in a supine position, and after demonstration of an adequate plane of general anesthesia via the nasotracheal route, patient was prepped and draped in the usual fashion for an intraoral procedure.  A gauze throat pack was placed and local anesthetic was administered in all four quadrants, a total of 7.2 mL of lidocaine 2% with 1:100,000 epinephrine, and 3.6 mL of bupivacaine 0.5% with 1:200,000 epinephrine.  Beginning on the upper right tooth #1, incision was made with a #15 blade.  Envelope flap was raised with the periosteal elevator, and bone was removed on the buccal aspect with straight elevator.  Potts elevator was then used to luxate the tooth from the socket.  Remnants of the follicle were then removed with hemostat.  The area was irrigated and then closed with 3-0 gut suture.  On the lower right tooth #32, incision was made with a #15 blade.  Envelope flap was raised with the periosteal elevator, and bone was removed on the buccal and distal aspect with a high-speed drill with a round bur.  Tooth was then sectioned with the bur and removed in several pieces.  Remnants of the follicle were removed with a curved hemostat.  The area was irrigated with normal saline solution and closed with 3-0 gut sutures.  Moving to #16 on the upper left, incision was made with a #15 blade.  Envelope flap was raised with the periosteal elevator, and bone was removed on the buccal aspect with straight elevator.  Potts elevator was then used to luxate the tooth from the socket.  Remnants of the follicle were removed with a curved hemostat.  The area was irrigated with normal saline solution and closed with 3-0 gut sutures.  Moving to the lower left #17, incision was made with a #15 blade.  Envelope flap was  raised with the periosteal elevator, and bone was removed on the buccal and distal aspect with high-speed drill with a round bur.  Then the bur was used to section the tooth vertically.  Tooth was removed in several pieces followed by the removal of the remnants of the follicle.  The area was irrigated with normal saline solution and closed with 3-0 gut sutures.  Upon completion of the procedure, the throat pack was removed and the pharynx was suctioned.  An NG tube was then inserted and small amount of gastric contents were suctioned.  Patient was then awakened, extubated, and taken to the PACU in stable condition.
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DESCRIPTION: Surgical removal of completely bony impacted teeth #1, #16, #17, and #32.  Completely bony impacted teeth #1, #16, #17, and #32.

dentistry, intraoral, bony impacted teeth, throat pack, buccal aspect, saline solution, gut sutures, envelope flap, periosteal elevator,

The procedure described is the surgical removal of four completely bony impacted wisdom teeth, which is a common and routine surgical intervention in the field of dentistry. While it involves general anesthesia and requires skill to ensure that the teeth are removed without complications, it is generally considered a low to moderate stakes procedure. The fact that there were no complications noted and the patient was stable post-operation also indicates that the situation was handled smoothly. The description does not mention any factors that would elevate the stakes, such as pre-existing health conditions that could increase surgical risk.


Medical Specialty: Gastroenterology
Sample Name: EGD - 2

PROCEDURES PERFORMED: , Esophagogastroduodenoscopy.,PREPROCEDURE DIAGNOSIS: , Dysphagia.,POSTPROCEDURE DIAGNOSIS: , Active reflux esophagitis, distal esophageal stricture, ring due to reflux esophagitis, dilated with balloon to 18 mm.,PROCEDURE: , Informed consent was obtained prior to the procedure with special attention to benefits, risks, alternatives.  Risks explained as bleeding, infection, bowel perforation, aspiration pneumonia, or reaction to the medications.  Vital signs were monitored by blood pressure, heart rate, and oxygen saturation.  Supplemental O2 given.  Specifics of the procedure discussed.  The procedure was discussed with father and mother as the patient is mentally challenged.  He has no complaints of dysphagia usually for solids, better with liquids, worsening over the last 6 months, although there is an emergency department report from last year.  He went to the emergency department yesterday with beef jerky.,All of this reviewed.  The patient is currently on Cortef, Synthroid, Tegretol, Norvasc, lisinopril, DDAVP.  He is being managed for extensive past history due to an astrocytoma, brain surgery, hypothyroidism, endocrine insufficiency.  He has not yet undergone significant workup.  He has not yet had an endoscopy or barium study performed.  He is developmentally delayed due to the surgery, panhypopituitarism.,His family history is significant for his father being of mine, also having reflux issues, without true heartburn, but distal esophageal stricture.  The patient does not smoke, does not drink.  He is living with his parents.  Since his emergency department visitation yesterday, no significant complaints.,Large male, no acute distress.  Vital signs monitored in the endoscopy suite.  Lungs clear.  Cardiac exam showed regular rhythm.  Abdomen obese but soft.  Extremity exam showed large hands.  He was a Mallampati score A, ASA classification type 2.,The procedure discussed with the patient, the patient's mother.  Risks, benefits, and alternatives discussed.  Potential alternatives for dysphagia, such as motility disorder, given his brain surgery, given the possibility of achalasia and similar discussed.  The potential need for a barium swallow, modified barium swallow, and similar discussed.  All questions answered.  At this point, the patient will undergo endoscopy for evaluation of dysphagia, with potential benefit of the possibility to dilate him should there be a stricture.  He may have reflux symptoms, without complaining of heartburn.  He may benefit from a trial of PPI.  All of this reviewed.  All questions answered.,
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DESCRIPTION: Esophagogastroduodenoscopy, patient with dysphagia.

gastroenterology, distal esophageal stricture, reflux esophagitis, distal esophageal, esophageal stricture, barium swallow, esophagogastroduodenoscopy, esophagitis, esophageal, heartburn, stricture, endoscopy, reflux, dysphagia

The situation involves a medical procedure, specifically an esophagogastroduodenoscopy (EGD) being performed on a patient with dysphagia and a complex medical history. While the procedure is generally common and routine in gastroenterology, it does carry risks such as bleeding, infection, and bowel perforation, which makes it more significant than low-stakes reviews or consultations. The patient's existing conditions, including a history of brain surgery, hypothyroidism, endocrine insufficiency, and developmental delays add complexity, increasing the stakes. Furthermore, the family history and the fact that the patient was recently in the emergency department elevate the importance of this procedure to effectively diagnose and potentially treat significant underlying issues. However, given the procedure is performed with informed consent and special preparations, it's not at the highest risk level.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: CT Chest - 1

EXAM: , CT chest with contrast.,REASON FOR EXAM: , Pneumonia, chest pain, short of breath, and coughing up blood.,TECHNIQUE: , Postcontrast CT chest 100 mL of Isovue-300 contrast.,FINDINGS: , This study demonstrates a small region of coalescent infiltrates/consolidation in the anterior right upper lobe.  There are linear fibrotic or atelectatic changes associated with this.  Recommend followup to ensure resolution.  There is left apical scarring.  There is no pleural effusion or pneumothorax.  There is lingular and right middle lobe mild atelectasis or fibrosis.,Examination of the mediastinal windows disclosed normal inferior thyroid.  Cardiac and aortic contours are unremarkable aside from mild atherosclerosis.  The heart is not enlarged.  There is no pathologic adenopathy identified in the chest including the bilateral axillary and hilar regions.,Very limited assessment of the upper abdomen demonstrates no definite abnormalities.,There are mild degenerative changes in the thoracic spine.,IMPRESSION:,1.Anterior small right upper lobe infiltrate/consolidation.  Recommend followup to ensure resolution given its consolidated appearance.,2.Bilateral atelectasis versus fibrosis.
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DESCRIPTION: CT chest with contrast.

CT chest with contrast.

cardiovascular / pulmonary, pneumonia, chest pain, short of breath, coughing up blood, upper lobe infiltrate, ct chest, ct, chest, isovue,

The situation involves a medical context with the potential for significant health implications given the findings in the CT chest scan, such as pneumonia, atelectasis, fibrosis, and coughing up blood. These conditions could lead to serious health issues if not monitored or treated properly. Therefore, timely and accurate follow-up is crucial for the patient's health. However, the findings do not indicate an immediate life-threatening emergency, but rather suggest the need for careful follow-up and management. Hence, while significant, it does not reach the highest level of urgency.


Medical Specialty: Neurology
Sample Name: Impairment Rating

CHIEF COMPLAINT: , Right shoulder pain.,HISTORY: , The patient is a pleasant, 31-year-old, right-handed, white female who injured her shoulder while transferring a patient back on 01/01/02.  She formerly worked for Veteran's Home as a CNA.  She has had a long drawn out course of treatment for this shoulder.  She tried physical therapy without benefit and ultimately came to a subacromion decompression in November 2002.  She had ongoing pain and was evaluated by Dr. X who felt that she had a possible brachial plexopathy.  He also felt she had a right superficial radial neuritis and blocked this with resolution of her symptoms.  He then referred her to ABCD who did EMG testing, demonstrating a right suprascapular neuropathy although a C5 radiculopathy could not be ruled out.  MRI testing on the cervical spine was then done which was negative for disk herniation and she underwent suprascapular nerve decompression of the scapular notch on 12/18/03.  She finally went to an anterior axillary nerve block because of ongoing pain in the anterior shoulder again by Dr. X.  She comes to me for impairment rating.  She has no chronic health problems otherwise, fevers, chills, or general malaise.  She is not working.  She is right-hand dominant.  She denies any prior history of injury to her shoulder.,PAST MEDICAL HISTORY:,  Negative aside from above.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY:  ,Please see above.,REVIEW OF SYSTEMS:,  Negative aside from above.,PHYSICAL EXAMINATION:  ,A pleasant, age appropriate woman, moderately overweight, in no apparent distress.  Normal gait and station, normal posture, normal strength, tone, sensation and deep tendon reflexes with the exception of 4+/5 strength in the supraspinatus musculature on the right.  She has decreased motion in the right shoulder as follows.  She has 160 degrees of flexion, 155 degrees of abduction, 35 degrees of extension, 25 degrees of adduction, 45 degrees of internal rotation and 90 degrees of external rotation.  She has a positive impingement sign on the right.,ASSESSMENT:,  Right shoulder impingement syndrome, right suprascapular neuropathy.,DISCUSSION: , With a reasonable degree of medical certainty, she is at maximum medical improvement and she does have an impairment based on AMA Guide to the Evaluation of Permanent Impairment, Fifth Edition.  The reason for this impairment is the incident of 01/01/02.  For her suprascapular neuropathy, she is rated as a grade IV motor deficit which I rate as a 13% motor deficit.  This is multiplied by a maximum upper extremity impairment for involvement of the suprascapular nerve of 16% which produces a 2% impairment of the upper extremity when the two values are multiplied together, 2% impairment of the upper extremity.  For her lack of motion in the shoulder she also has additional impairment on the right.  She has a 1% impairment of the upper extremity due to lack of shoulder flexion.  She has a 1% impairment of the upper extremity due to lack of shoulder abduction.  She has a 1% impairment of the upper extremity due to lack of shoulder adduction.  She has a 1% impairment of the upper extremity due to lack of shoulder extension.  There is no impairment for findings in shoulder external rotation.  She has a 3% impairment of the upper extremity due to lack of shoulder internal rotation.  Thus the impairment due to lack of motion in her shoulder is a 6% impairment of the upper extremity.  This combines with the 2% impairment of the upper extremity due to weakness in the suprascapular nerve root distribution to produce an 8% impairment of the upper extremity which in turn is a 5% impairment of the whole person based on the AMA Guide to the Evaluation of Permanent Impairment, Fifth Edition, stated with a reasonable degree of medical certainty.
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DESCRIPTION: Right shoulder impingement syndrome, right suprascapular neuropathy.

neurology, ama guide, evaluation of permanent impairment, impairment rating, permanent impairment, suprascapular nerve, suprascapular neuropathy, injured, extremity, shoulder, impairment, neuropathy, suprascapular,

The situation involves a medical evaluation for an impairment rating related to a shoulder injury and its neurological complications. While the condition affects the patient's ability to work and perform daily activities, there is no immediate threat to life or significant risk of severe health deterioration. It is a standard impairment assessment for a chronic injury, which is routine in medical and legal contexts but not high-stakes in a critical, urgent sense.


Medical Specialty: Consult - History and Phy.
Sample Name: Hip Fracture - ER Consult

REASON FOR CONSULTATION: , Left hip fracture.,HISTORY OF PRESENT ILLNESS: , The patient is a pleasant 53-year-old female with a known history of sciatica, apparently presented to the emergency room due to severe pain in the left lower extremity and unable to bear weight.  History was obtained from the patient.  As per the history, she reported that she has been having back pain with left leg pain since past 4 weeks.  She has been using a walker for ambulation due to disabling pain in her left thigh and lower back.  She was seen by her primary care physician and was scheduled to go for MRI yesterday.  However, she was walking and her right foot got caught on some type of rug leading to place excessive weight on her left lower extremity to prevent her fall.  Since then, she was unable to ambulate.  The patient called paramedics and was brought to the emergency room.  She denied any history of fall.  She reported that she stepped the wrong way causing the pain to become worse.  She is complaining of severe pain in her lower extremity and back pain.  Denies any tingling or numbness.  Denies any neurological symptoms.  Denies any bowel or bladder incontinence.,X-rays were obtained which were remarkable for left hip fracture.  Orthopedic consultation was called for further evaluation and management.  On further interview with the patient, it is noted that she has a history of malignant melanoma, which was diagnosed approximately 4 to 5 years ago.  She underwent surgery at that time and subsequently, she was noted to have a spread to the lymphatic system and lymph nodes for which she underwent surgery in 3/2008.,PAST MEDICAL HISTORY: , Sciatica and melanoma.,PAST SURGICAL HISTORY:  ,As discussed above, surgery for melanoma and hysterectomy.,ALLERGIES: , NONE.,SOCIAL HISTORY: , Denies any tobacco or alcohol use.  She is divorced with 2 children.  She lives with her son.,PHYSICAL EXAMINATION:,GENERAL:  The patient is well developed, well nourished in mild distress secondary to left lower extremity and back pain.,MUSCULOSKELETAL:  Examination of the left lower extremity, there is presence of apparent shortening and external rotation deformity.  Tenderness to palpation is present.  Leg rolling is positive for severe pain in the left proximal hip.  Further examination of the spine is incomplete secondary to severe leg pain.  She is unable to perform a straight leg raising.  EHL/EDL 5/5.  2+ pulses are present distally.  Calf is soft and nontender.  Homans sign is negative.  Sensation to light touch is intact.,IMAGING:,  AP view of the hip is reviewed.  Only 1 limited view is obtained.  This is a poor quality x-ray with a lot of soft tissue shadow.  This x-ray is significant for basicervical-type femoral neck fracture.  Lesser trochanter is intact.  This is a high intertrochanteric fracture/basicervical.  There is presence of lytic lesion around the femoral neck, which is not well delineated on this particular x-ray.  We need to order repeat x-rays including AP pelvis, femur, and knee.,LABS:,  Have been reviewed.,ASSESSMENT: , The patient is a 53-year-old female with probable pathological fracture of the left proximal femur.,DISCUSSION AND PLAN: , Nature and course of the diagnosis has been discussed with the patient.  Based on her presentation without any history of obvious fall or trauma and past history of malignant melanoma, this appears to be a pathological fracture of the left proximal hip.  At the present time, I would recommend obtaining a bone scan and repeat x-rays, which will include AP pelvis, femur, hip including knee.  She denies any pain elsewhere.  She does have a past history of back pain and sciatica, but at the present time, this appears to be a metastatic bone lesion with pathological fracture.  I have discussed the case with Dr. X and recommended oncology consultation.,With the above fracture and presentation, she needs a left hip hemiarthroplasty versus calcar hemiarthroplasty, cemented type.  Indication, risk, and benefits of left hip hemiarthroplasty has been discussed with the patient, which includes, but not limited to bleeding, infection, nerve injury, blood vessel injury, dislocation early and late, persistent pain, leg length discrepancy, myositis ossificans, intraoperative fracture, prosthetic fracture, need for conversion to total hip replacement surgery, revision surgery, DVT, pulmonary embolism, risk of anesthesia, need for blood transfusion, and cardiac arrest.  She understands above and is willing to undergo further procedure.  The goal and the functional outcome have been explained.  Further plan will be discussed with her once we obtain the bone scan and the radiographic studies.  We will also await for the oncology feedback and clearance.,Thank you very much for allowing me to participate in the care of this patient.  I will continue to follow up.
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DESCRIPTION: Left hip fracture.  The patient is a 53-year-old female with probable pathological fracture of the left proximal femur.

consult - history and phy., calcar, proximal femur, pathological fracture, hip, fracture, hemiarthroplasty, melanoma,

The situation involves a 53-year-old female with a probable pathological fracture of the left hip, potentially related to her history of malignant melanoma. This condition is high-stakes due to the potential implications of metastatic cancer, the immediate need for surgical intervention, and the associated risks and complications that can significantly impact the patient's health and quality of life. Additionally, the condition requires prompt action and interdisciplinary cooperation between orthopedics and oncology. Therefore, the situation has considerable medical urgency and complexity.


Medical Specialty: Physical Medicine - Rehab
Sample Name: Physical Therapy - Back Pain

DIAGNOSIS: , Low back pain and degenerative lumbar disk.,HISTORY:,  The patient is a 59-year-old female, who was referred to Physical Therapy, secondary to low back pain and degenerative disk disease.  The patient states she has had a cauterization of some sort to the nerves in her low back to help alleviate with painful symptoms.  The patient states that this occurred in October 2008 as well as November 2008.  The patient has a history of low back pain, secondary to a fall that originally occurred in 2006.  The patient states that she slipped on a newly waxed floor and fell on her tailbone and low back region.  The patient then had her second fall in March 2006.  The patient states that she was qualifying on the range with a handgun and lost her footing and states that she fell more due to weakness in her lower extremities rather than loss of balance.,PAST MEDICAL HISTORY:,  Past medical history is significant for allergies and thyroid problems.,PAST SURGICAL HISTORY: , The patient has a past surgical history of appendectomy and hysterectomy.,MEDICATIONS:,1.  TriCor.,2.  Vytorin.,3.  Estradiol.,4.  Levothyroxine.,5.  The patient is also taking ibuprofen 800 mg occasionally as needed for pain management.  The patient states she rarely takes this and does not like to take pain medication if at all possible.  The patient states that she has had uncomplicated pregnancies in the past.,SOCIAL HISTORY:,  The patient states she lives in a single-level home with her husband, who is in good health and is able to assist with any tasks or activities the patient is having difficulty with.  The patient rates her general health as excellent and denies any smoking and reports very occasional alcohol consumption.  The patient does state that she has completed exercises on a daily basis of one to one and a half hours a day.  However, has not been able to complete these exercise routine since approximately June 2008, secondary to back pain.  The patient is working full-time as a project manager, and is required to do extensive walking at various periods during a workday.,MEDICAL IMAGING:,  The patient states that she has had an MRI recently performed; however, the results are not available at the time of the evaluation.  The patient states she is able to bring the report in upon next visit.,SUBJECTIVE:  ,The patient rates her pain at 7/10 on a Pain Analog Scale, 0 to 10, 10 being worse.  The patient describes her pain as a deep aching, primarily on the right lower back and gluteal region.  Aggravating factors include stairs and prolonged driving, as well as general limitations with home tasks and projects.  The patient states she is a very active individual and is noticing extreme limitations with ability to complete home tasks and projects she used to be able to complete.,NEUROLOGICAL SYMPTOMS:,  The patient reports having occasional shooting pains into the lower extremities.  However, these are occurring less frequently and is now occurring more frequently in the right versus the left lower extremity when they do occur.,FUNCTIONAL ACTIVITIES AND HOBBIES: , Include exercising and general activities.,PATIENT'S GOAL: , The patient would like to improve her overall body movements and return to daily exercise routine as able and well maintaining safety.,OBJECTIVE: , Upon observation, the patient ambulates independently without the use of assistive device.  However, does present with mild limp and favoring the left lower extremity after extensive standing and walking activity.  The patient does have mild difficulty transferring from the seated position to standing.  However, once is upright, the patient denies any increased pain or symptoms.,ACTIVE RANGE OF MOTION OF LUMBAR SPINE:  ,Forward flexion is 26 cm, fingertip to floor, lateral side bend, fingertip to floor is 52.5 cm bilaterally.,STRENGTH: , Strength is grossly 4/5.  The patient denies any significant tenderness to palpation.  However, does have mild increase in tenderness on the right versus left.  A six-minute walk test revealed painful symptoms and achiness occurring after approximately 400 feet of walking.  The patient was able to continue; however, stopped after 700 feet.  There were two minutes remaining in the six-minute walk test.  The patient does have tight hamstrings as well as a negative slump test.,ASSESSMENT: , The patient would benefit from skilled physical therapy intervention in order to address the following problem list.,PROBLEM LIST:,1.  Increased pain.,2.  Decreased ability to complete tasks and hobbies.,3
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DESCRIPTION: Patient was referred to Physical Therapy, secondary to low back pain and degenerative disk disease.  The patient states she has had a cauterization of some sort to the nerves in her low back to help alleviate with painful symptoms.  The patient would benefit from skilled physical therapy intervention.

The situation involves a patient experiencing low back pain and limitations in daily functioning, which affects her quality of life, physical capabilities, and work performance. However, it is not immediately life-threatening or an emergency. The patient has a clear treatment plan, which involves physical therapy and careful management of symptoms. Her condition, while serious and impacting her daily life, doesn't present immediate critical risks such as loss of mobility, paralysis, or severe deterioration in health. Nonetheless, effective management and intervention are important to prevent worsening and to improve quality of life, making it moderately high-stakes.


Medical Specialty: Consult - History and Phy.
Sample Name: Angina - Consult

HISTORY OF PRESENT ILLNESS: , The patient is a 68-year-old woman whom I have been following, who has had angina.  In any case today, she called me because she had a recurrent left arm pain after her stent, three days ago, and this persisted after two sublingual nitroglycerin when I spoke to her.  I advised her to call 911, which she did.  While waiting for 911, she was attended to by a physician who is her neighbor and he advised her to take the third nitroglycerin and that apparently relieved her pain.  By the time she presented here, she is currently pain-free and is feeling well.,PAST CARDIAC HISTORY: , The patient has been having arm pain for several months.  She underwent an exercise stress echocardiogram within the last several months with me, which was equivocal, but then she had a nuclear stress test which showed inferobasilar ischemia.  I had originally advised her for a heart catheterization but she wanted medical therapy, so we put her on a beta-blocker.  However, her arm pain symptoms accelerated and she had some jaw pain, so she presented to the emergency room.  On 08/16/08, she ended up having a cardiac catheterization and that showed normal left main 80%  mid LAD lesion, circumflex normal, and RCA totally occluded in the mid portion and there were collaterals from the left to the right, as well as right to right to that area.  The decision was made to transfer  her as she may be having collateral insufficiency from the LAD stenosis to the RCA vessel.  She underwent that with drug-eluting stents on 08/16/08, with I believe three or four total placed, and was discharged on 08/17/08.  She had some left arm discomfort on 08/18/08, but this was mild.  Yesterday, she felt very fatigued, but no arm pain, and today, she had arm pain after walking and again it resolved now completely after three sublingual nitroglycerin.  This is her usual angina.  She is being admitted with unstable angina post stent.,PAST MEDICAL HISTORY: , Longstanding hypertension, CAD as above, hyperlipidemia, and overactive bladder.,MEDICATIONS:,1.  Detrol LA 2 mg once a day.,2.  Prilosec for GERD 20 mg once a day.,3.  Glucosamine 500/400 mg once a day for arthritis.,4.  Multivitamin p.o. daily.,5.  Nitroglycerin sublingual as available to her.,6.  Toprol-XL 25 mg once a day which I started although she had been bradycardic, but she seems to be tolerating.,7.  Aspirin 325 mg once a day.,8.  Plavix 75 mg once a day.,9.  Diovan 160 mg once a day.,10.  Claritin 10 mg once a day for allergic rhinitis.,11.  Norvasc 5 mg once a day.,12.  Lipitor 5 mg once a day.,13.  Evista 60 mg once a day.,ALLERGIES: , ALLERGIES TO MEDICATIONS ARE NONE.  SHE DENIES ANY SHRIMP OR SEA FOOD ALLERGY.,FAMILY HISTORY: , Her father died of an MI in his 50s and a brother had his first MI and bypass surgery at 54.,SOCIAL HISTORY:  ,She does not smoke cigarettes, abuse alcohol, no use of illicit drugs.  She is divorced and lives alone and is a retired laboratory technician from Cornell Diagnostic Laboratory.,REVIEW OF SYSTEMS:,  She denies a history of stroke, cancer, vomiting up blood, coughing up blood, bright red blood per rectum, bleeding stomach ulcers, renal calculi, cholelithiasis, asthma, emphysema, pneumonia, tuberculosis, home oxygen use or sleep apnea, although she has been told in the past that she snores and there was some question of apnea in 05/08.  No morning headaches or fatigue.  No psychiatric diagnosis.  No psoriasis, no lupus.  Remainder of the review of systems is negative x14 systems except as described above.,PHYSICAL EXAMINATION:,GENERAL:  She is a pleasant elderly woman, currently in no acute distress.,VITAL SIGNS:  Height 4 feet 11 inches, weight 128 pounds, temperature 97.2 degrees Fahrenheit, blood pressure 142/70, pulse 47,  respiratory rate 16, and O2 saturation 100%,HEENT:  Cranium is normocephalic and atraumatic.  She has moist mucosal membranes.,NECK:  Veins are not distended.  There are no carotid bruits.,LUNGS:  Clear to auscultation and percussion without wheezes.,HEART:  S1 and S2, regular rate.  No significant murmurs, rubs or gallops.  PMI nondisplaced.,ABDOMEN:  Soft and nondistended.  Bowel sounds present.,EXTREMITIES:  Without significant clubbing, cyanosis or edema.  Pulses grossly intact.  Bilateral groins are inspected, status post as the right femoral artery was used for access for the diagnostic cardiac catheterization here and left femoral artery used for PCI and there is no evidence of hematoma or bruit and intact distal pulses.,LABORATORY DATA: , EKG reviewed which shows sinus bradycardia at the rate of 51 beats per minute and no acute disease.,Sodium 136, potassium 3.8, chloride 105, and bicarbonate 27.  BUN 16 and creatinine 0.9.  Glucose 110.  Magnesium 2.5.  ALT 107 and AST 65 and these were normal on 08/15/08.  INR is 0.89, PTT 20.9, white blood cell count 8.2, hematocrit 31 and it was 35 on 08/15/08, and platelet count 257,000.,IMPRESSION AND PLAN:  ,The patient is a 68-year-old woman with exertional angina, characterized with arm pain, who underwent recent left anterior descending percutaneous coronary intervention and has now had recurrence of that arm pain post stenting to the left anterior descending artery and it may be that she is continuing to have collateral insufficiency of the right coronary artery.  In any case, given this unstable presentation requiring three sublingual nitroglycerin before she was even pain free, I am going to admit her to the hospital and there is currently no evidence requiring acute reperfusion therapy.  We will continue her beta-blocker and I cannot increase the dose because she is bradycardic already.  Aspirin, Plavix, valsartan, Lipitor, and Norvasc.  I am going to add Imdur and watch headaches as she apparently had some on nitro paste before, and we will rule out MI, although there is a little suspicion.  I suppose it is possible that she has non-cardiac arm pain, but that seems less likely as it has been nitrate responsive and seems exertionally related and the other possibility may be that we end up needing to put in a pacemaker, so we can maximize beta-blocker use for anti-anginal effect.  My concern is that there is persistent right coronary artery ischemia, not helped by left anterior descending percutaneous coronary intervention, which was severely stenotic and she does have normal LV function.  She will continue the glucosamine for her arthritis, Claritin for allergies, and Detrol LA for urinary incontinence.,Total patient care time in the emergency department 75 minutes.  All this was discussed in detail with the patient and her daughter who expressed understanding and agreement.  The patient desires full resuscitation status.
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DESCRIPTION: Patient had a recurrent left arm pain after her stent, three days ago, and this persisted after two sublingual nitroglycerin.

The patient is experiencing recurrent angina and persistent symptoms following a recent percutaneous coronary intervention (PCI), indicating potential complications or insufficient treatment of a critical heart condition. Unstable angina post-stenting is concerning and could escalate to a myocardial infarction if not managed properly. The need for close monitoring, possible adjustments in medication, and consideration of additional interventions (e.g., pacemaker, further stenting) suggest that this is a high-stakes situation necessitating careful medical attention.


Medical Specialty: Consult - History and Phy.
Sample Name: Orthopedic Consult - 2

SUBJECTIVE:,  The patient comes back to see me today.  She is a pleasant 77-year-old Caucasian female who had seen Dr. XYZ with right leg pain.  She has a history of prior laminectomy for spinal stenosis.  She has seen Dr. XYZ with low back pain and lumbar scoliosis post laminectomy syndrome, lumbar spinal stenosis, and clinical right L2 radiculopathy, which is symptomatic.  Dr. XYZ had performed two right L2-L3 transforaminal epidural injections, last one in March 2005.  She was subsequently seen and Dr. XYZ found most of her remaining symptoms are probably coming from her right hip.  An x-ray of the hip showed marked degenerative changes with significant progression of disease compared to 08/04/2004 study.  Dr. XYZ had performed right intraarticular hip injection on 04/07/2005.  She was last seen on 04/15/2005.  At that time, she had the hip injection that helped her briefly with her pain.  She is not sure whether or not she wants to proceed with hip replacement.  We recommend she start using a cane and had continued her on some pain medicines.,The patient comes back to see me today.  She continues to complain of significant pain in her right hip, especially with weightbearing or with movement.  She said she had made an appointment to see an orthopedic surgeon in Newton as it is closer and more convenient for her.  She is taking Ultracet or other the generic it sounds like, up to four times daily.  She states she can take this much more frequently as she still has significant pain symptoms.  She is using a cane to help her ambulate.,PAST MEDICAL HISTORY:,  Essentially unchanged from her visit of 04/15/2005.,PHYSICAL EXAMINATION:,General:  Reveals a pleasant Caucasian female.,Vital Signs:  Height is 5 feet 4 inches.  Weight is 149 pounds.  She is afebrile.,HEENT:  Benign.,Neck:  Shows functional range of movements with a negative Spurling's.,Musculoskeletal:  Examination shows some mild degenerative joint disease of both knees with grade weakness of her right hip flexors and half-grade weakness of her right hip adductors and right quadriceps, as compared to the left.  Straight leg raises are negative bilaterally.  Posterior tibials are palpable bilaterally.,Skin and Lymphatics:  Examination of the skin does not reveal any additional scars, rashes, cafe au lait spots or ulcers.  No significant lymphadenopathy noted.,Spine:  Examination shows lumbar scoliosis with surgical scar with no major tenderness.  Spinal movements are limited but functional.,Neurological:  She is alert and oriented with appropriate mood and affect.  She has normal tone and coordination.  Reflexes are 2+ and symmetrical.  Sensations are intact to pinprick.,FUNCTIONAL EXAMINATION:,  Gait has a normal stance and swing phase with no antalgic component to it.,IMPRESSION:,1.  Degenerative disk disease of the right hip, symptomatic.,2.  Low back syndrome, lumbar spinal stenosis, clinically right L2 radiculopathy, stable.,3.  Low back pain with lumbar scoliosis post laminectomy syndrome, stable.,4.  Facet and sacroiliac joint syndrome on the right, stable.,5.  Post left hip arthroplasty.,6.  Chronic pain syndrome.,RECOMMENDATIONS:,  The patient is symptomatic primarily on her right hip and is planning on seeing an orthopedic surgeon for possible right hip replacement.  In the interim, her Ultracet is not quite taking care of her pain.  I have asked her to discontinue it and we will start her on Tylenol #3, up to four times a day.  I have written a prescription for this for 120 tablets and two refills.  The patient will call for the refills when she needs them.  I will plan further follow up in six months, sooner if needed.  She voiced understanding and is in agreement with this plan.  Physical exam findings, history of present illness and recommendations were performed with and in agreement with Dr. Goel's findings.
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DESCRIPTION: Degenerative disk disease of the right hip, low back pain with lumbar scoliosis post laminectomy syndrome, lumbar spinal stenosis, facet and sacroiliac joint syndrome, and post left hip arthroplasty.

consult - history and phy., scoliosis, lumbar, laminectomy, spinal stenosis, radiculopathy, chronic pain syndrome, low back pain, facet and sacroiliac joint, degenerative disk disease, sacroiliac joint syndrome, lumbar spinal stenosis, disk disease, sacroiliac joint, hip arthroplasty, hip injection, hip replacement, lumbar scoliosis, injections, hip, orthopedic,

The situation involves a 77-year-old patient with a history of complex orthopedic issues, including degenerative disk disease, lumbar stenosis, and chronic pain, which are affecting her mobility and quality of life. While she is experiencing significant pain and is contemplating hip replacement surgery, the situation is not immediately life-threatening. However, it is a high-stakes decision from a quality-of-life and long-term health perspective, as the outcome could significantly impact her daily functioning and well-being. The high-stakes nature is also influenced by her age and complex medical history, which may complicate surgical outcomes or recovery.


Medical Specialty: Urology
Sample Name: Ultrasound Scrotum

EXAM: , Ultrasound examination of the scrotum.,REASON FOR EXAM: , Scrotal pain.,FINDINGS:  ,Duplex and color flow imaging as well as real time gray-scale imaging of the scrotum and testicles was performed.  The left testicle measures 5.1 x 2.8 x 3.0 cm.  There is no evidence of intratesticular masses.  There is normal Doppler blood flow.  The left epididymis has an unremarkable appearance.  There is a trace hydrocele.,The right testicle measures 5.3 x 2.4 x 3.2 cm.  The epididymis has normal appearance.  There is a trace hydrocele.  No intratesticular masses or torsion is identified.  There is no significant scrotal wall thickening.,IMPRESSION:  ,Trace bilateral hydroceles, which are nonspecific, otherwise unremarkable examination.
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DESCRIPTION: Ultrasound examination of the scrotum due to scrotal pain.  Duplex and color flow imaging as well as real time gray-scale imaging of the scrotum and testicles was performed.

urology, scrotal pain, epididymis, torsion, ultrasound examination, intratesticular masses, ultrasound, scrotal, testicles, scrotum,

The situation involves a medical examination for scrotal pain using an ultrasound. The findings indicate trace bilateral hydroceles but no significant issues such as intratesticular masses or torsion, which can be more serious conditions. Hydroceles are often non-specific and may not require urgent treatment unless symptomatic or problematic. Given the findings, this situation is not high-stakes in a medical context.


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

Medical Specialty: Surgery
Sample Name: Direct Laryngoscopy

PREOPERATIVE DIAGNOSIS:,  Subglottic stenosis.,POSTOPERATIVE DIAGNOSIS: , Subglottic stenosis.,OPERATIVE PROCEDURES: , Direct laryngoscopy and bronchoscopy.,ANESTHESIA:,  General inhalation.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room and placed supine on the operative table.  General inhalational anesthesia was administered through the patient's tracheotomy tube.  The small Parsons laryngoscope was inserted and the 2.9-mm telescope was used to inspect the airway.  There was an estimated 60-70% circumferential mature subglottic stenosis that extended from just under the vocal folds to approximately 3 mm below the vocal folds.  The stoma showed some suprastomal fibroma.  The remaining tracheobronchial passages were clear.  The patient's 3.5 neonatal tracheostomy tube was repositioned and secured with Velcro ties.  Bleeding was negligible.  There were no untoward complications.  The patient tolerated the procedure well and was transferred to recovery room in stable condition.
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DESCRIPTION: Direct laryngoscopy and bronchoscopy.

Direct laryngoscopy and bronchoscopy.

surgery, laryngoscopy and bronchoscopy, direct laryngoscopy, subglottic stenosis, bronchoscopy, laryngoscopy, subglottic, stenosis,

This procedure involves a direct laryngoscopy and bronchoscopy to address subglottic stenosis, a significant narrowing of the airway just below the vocal cords. The situation is high-stakes due to the location and potential implications of the condition, which can lead to airway obstruction. Surgery involving the airway carries inherent risks, although there were no complications in this case. However, such an operation remains critical as it concerns a patient's ability to breathe. Successful management of airway stenosis is crucial to prevent life-threatening situations. Given these factors, the stakes involved are high, warranting careful attention to detail and precise execution by the surgical team.


Medical Specialty: Orthopedic
Sample Name: Spinal Fusion & Instrumentation

PREOPERATIVE DIAGNOSIS: , Severe scoliosis.,ANESTHESIA: , General.  Lines were placed by Anesthesia to include an A line.,PROCEDURES: ,1.  Posterior spinal fusion from T2-L2.,2.  Posterior spinal instrumentation from T2-L2.,3.  A posterior osteotomy through T7-T8 and T8-T9.  Posterior elements to include laminotomy-foraminotomy and decompression of the nerve roots.,IMPLANT: , Sofamor Danek (Medtronic) Legacy 5.5 Titanium system.,MONITORING: , SSEPs, and the EPs were available.,INDICATIONS: , The patient is a 12-year-old female, who has had a very dysmorphic scoliosis.  She had undergone a workup with an MRI, which showed no evidence of cord abnormalities.  Therefore, the risks, benefits, and alternatives were discussed with Surgery with the mother, to include infections, bleeding, nerve injuries, vascular injuries, spinal cord injury with catastrophic loss of motor function and bowel and bladder control.  I also discussed ___________ and need for revision surgery.  The mom understood all this and wished to proceed.,PROCEDURE: , The patient was taken to the operating room and underwent general anesthetic.  She then had lines placed, and was then placed in a prone position.  Monitoring was then set up, and it was then noted that we could not obtain motor-evoked potentials.  The SSEPs were clear and were compatible with the preoperative, but no preoperative motors had been done, and there was a concern that possibly this could be from the result of the positioning.  It was then determined at that time, that we would go ahead and proceed to wake her up, and make sure she could move her feet.  She was then lightened under anesthesia, and she could indeed dorsiflex and plantarflex her feet, so therefore, it was determined to go ahead and proceed with only monitoring with the SSEPs.,The patient after being prepped and draped sterilely, a midline incision was made, and dissection was carried down.  The dissection utilized a combination of hand instruments and electrocautery and dissected out along the laminae and up to the transverse processes.  This occurred from T2-L2.  Fluoroscopy was brought in to verify positions and levels.  Once this was done, and all bleeding was controlled, retractors were then placed.  Attention was then turned towards placing screws first on the left side.  Lumbar screws were placed at the junction of the transverse process and the facets under fluoroscopic guidance.  The area was opened with a high speed burr, and then the track was defined with a blunt probe, and a ball-tipped feeler was then utilized to verify all walls were intact.  They were then tapped, and then screws were then placed.  This technique was used at L1 and L2, both the right and left.  At T12, a direct straight-ahead technique was utilized, where the facet was removed, and then the position was chosen under the fluoroscopy, and then it was spurred, the track was defined and then probed and tapped, and it was felt to be in good position.  Two screws, in the right and left were placed at T12 as well, reduction screws on the left.  The same technique was used for T11, where right and left screws were placed as well as T10 on the left.  At T9, a screw was placed on the left, and this was a reduction screw.  On the left at T8, a screw could not be placed due to the dysmorphic nature of the pedicle.  It was not felt to be intact; therefore, a screw was left out of this.  On the right, a thoracic screw was placed as well as at 7 and 6.  This was the dysmorphic portion of this.  Screws were attempted to be placed up, they could not be placed, so attention was then turned towards placing pedicle hooks.  Pedicle hooks were done by first making a box out of the pedicle, removing the complete pedicle, feeling the undersurface of the pedicle with a probe, and then seating the hook.  Upgoing pedicle hooks were placed at T3, T4, and T5.  A downgoing laminar hook was placed at the T7 level.  Screws had been placed at T6 and T7 on the right.  An upgoing pedicle hook was also placed at T3 on the right, and then, downgoing laminar hooks were placed at T2.  This was done by first using a transverse process, lamina finders to go around the transverse process and then ___________ laminar hooks.  Once all hooks were in place, spinal osteotomies were performed at T7-T8 and T8-T9.  This was the level of the kyphosis, to bring her back out of her kyphoscoliosis.  First the ligamentum flavum was resected using a large Kerrisons.  Next, the laminotomy was performed, and then a Kerrison was used to remove the ligamentum flavum at the level of the facet.  Once this was accomplished, a laminotomy was performed by removing more of the lamina, and to create a small wedge that could be closed down later to correct the kyphosis.  This was then brought out with resection of bone out to the foramen, doing a foraminotomy to free up the foramen on both sides.  This was done also between the T8-T9.  Once this was completed, Gelfoam was then placed.  Next, we observed, and measured and contoured.  The rods were then seated on the left, and then a derotation maneuver was performed.  Hooks had come loose, so the rod was removed on the left.  The hooks were then replaced, and the rod was reseated.  Again, it was derotated to give excellent correction.  Hooks were then well seated underneath, and therefore, they were then locked.  A second rod was then chosen on the right, and was measured, contoured, and then seated.  Next, once this was done, the rods were locked in the midsubstance, and then the downgoing pedicle hook, which had been placed at T7 was then helped to compress T8 as was the pedicle screw, and then this compressed the osteotomy sites quite nicely.  Next, distraction was then utilized to further correct at the spine, and to correct on the left, the left concave curve, which gave excellent correction.  On the right, compression was used to bring it down, and then, in the lower lumbar areas, distraction and compression were used to level out L2.  Once this was done, all screws were tightened.  Fluoroscopy was then brought in to verify L1 was level, and the first ribs were also level, and it gave a nice balanced spine.  Everything was copiously irrigated, ___________.  Next, a wake-up test was performed, and the patient was then noted to flex and extend the knees as well as dorsiflex and plantar flex both the feet.  The patient was then again sedated and brought back under general anesthesia.  Next, a high-speed burr was used for decortication.  After final tightening had been accomplished, and then allograft bone and autograft bone were mixed together with 10 mL of iliac crest aspirate and were placed into the wound.  The open canal areas had been protected with Gelfoam.  Once this was accomplished, the deep fascia was closed with multiple figure-of-eight #1's, oversewn with a running #1, _________ were then placed in the subcutaneous spaces which were then closed with 3-0 Vicryl, and then the skin was closed with 3-0 Monocryl and Dermabond.  Sterile dressing was applied.  Drains had been placed in the subcutaneous layer x2.  The patient during the case had no changes in the SSEPs, had a normal wake-up test, and had received Ancef and clindamycin during the case.  She was taken from the operating room in good condition.
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DESCRIPTION: Posterior spinal fusion and spinal instrumentation.  Posterior osteotomy; posterior elements to include laminotomy-foraminotomy and decompression of the nerve roots.

orthopedic, osteotomy, laminotomy-foraminotomy, sofamor danek, sseps, spinal fusion, transverse processes, pedicle hooks, pedicle, laminotomy, hooks, screws, instrumentation, decompression, scoliosis, sofamor, foraminotomy, spinal

The described procedure is a complex spinal surgery in a 12-year-old female with severe scoliosis, involving multiple surgical techniques like spinal fusion, instrumentation, osteotomies, and nerve decompression. The stakes are high because of the potential risks involved, such as spinal cord injury, nerve damage, infection, and the need for revision surgery, as well as the delicate nature of pediatric spinal surgery. This type of surgery requires high precision and can have significant consequences on the patient's future mobility and quality of life if complications occur. The patient's monitoring during anesthesia and the wake-up test highlight the critical nature of maintaining neurological integrity throughout the procedure.


Medical Specialty: Ophthalmology
Sample Name: Cataract Surgery

NORMAL CATARACT SURGERY,PROCEDURE DETAILS: , The patient was taken to the operating room where the Rand-Stein anesthesia protocol was followed using alfentanil and Brevital.  Topical tetracaine drops were applied.  The operative eye was prepped and draped in the usual sterile fashion.  A lid speculum was inserted.,Under the Zeiss operating microscope, a lateral clear corneal approach was utilized.  A stab incision was made with a diamond blade to the right of the lateral limbus and the anterior chamber filled with intracameral lidocaine and viscoelastic.  A 3-mm single pass clear corneal incision was made just anterior to the vascular arcade of the temporal limbus using a diamond keratome.  A 5- to 5.5-mm anterior capsulorrhexis was created.  The nucleus was hydrodissected and hydrodelineated, and was freely movable in the capsular bag.  The nucleus was then phacoemulsified using a quadrantic divide-and-conquer technique.  Following the deep groove formation, the lens was split bimanually and the resultant quadrants and epicortex removed under high-vacuum burst-mode phacoemulsification.  Peripheral cortex was removed with the irrigation and aspiration handpiece.  The posterior capsule was polished.  The capsular bag was expanded with viscoelastic.  The implant was inspected under the microscope and found to be free of defects.  The implant was inserted into the cartridge system under viscoelastic and placed in the capsular bag.  The trailing haptic was positioned with the cartridge system.  Residual viscoelastic was removed from the anterior chamber and from behind the implant.  The corneal wound was hydrated with balanced salt solution.  The anterior chamber was fully re-formed through the side-port incision.  The wound was inspected and found to be watertight.  The intraocular pressure was adjusted as necessary.  The lid speculum was removed.  Topical Timoptic drops, Eserine and Dexacidin ointment were applied.  The eye was shielded.  The patient appeared to tolerate the procedure well and left the operating room in stable condition.  Followup appointment is with Dr. X on the first postoperative day.
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DESCRIPTION: Normal cataract surgery.

Normal cataract surgery.

ophthalmology, zeiss, peripheral cortex, phacoemulsified, hydrodissected, rand-stein, lid speculum, anterior chamber, capsular bag, cataract, viscoelasticNOTE,: 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.,

This detailed account describes a routine cataract surgery, a common and generally low-risk procedure. Given its frequency and high success rate, it is considered low-stakes in comparison to more complex or emergency surgeries. The procedure went smoothly without any reported complications, further lowering the stakes.


Medical Specialty: Neurology
Sample Name: MRI Spine

INTERPRETATION: , MRI of the cervical spine without contrast showed normal vertebral body height and alignment with normal cervical cord signal.  At C4-C5, there were minimal uncovertebral osteophytes with mild associated right foraminal compromise.  At C5-C6, there were minimal diffuse disc bulge and uncovertebral osteophytes with indentation of the anterior thecal sac, but no cord deformity or foraminal compromise.  At C6-C7, there was a central disc herniation resulting in mild deformity of the anterior aspect of the cord with patent neuroforamina.  MRI of the thoracic spine showed normal vertebral body height and alignment.  There was evidence of disc generation, especially anteriorly at the T5-T6 level.  There was no significant central canal or foraminal compromise.  Thoracic cord normal in signal morphology.  MRI of the lumbar spine showed normal vertebral body height and alignment.  There is disc desiccation at L4-L5 and L5-S1 with no significant central canal or foraminal stenosis at L1-L2, L2-L3, and L3-L4.  There was a right paracentral disc protrusion at L4-L5 narrowing of the right lateral recess.  The transversing nerve root on the right was impinged at that level.  The right foramen was mildly compromised.  There was also a central disc protrusion seen at the L5-S1 level resulting in indentation of the anterior thecal sac and minimal bilateral foraminal compromise.,IMPRESSION: , Overall impression was mild degenerative changes present in the cervical, thoracic, and lumbar spine without high-grade central canal or foraminal narrowing.  There was narrowing of the right lateral recess at L4-L5 level and associated impingement of the transversing nerve root at that level by a disc protrusion.  This was also seen on a prior study.,
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DESCRIPTION: MRI of the Cervical, Thoracic, and Lumbar Spine

neurology, cervical spine, mri, cervical, thoracic, lumbar, transversing nerve root, vertebral body height, vertebral body, disc protrusion, foraminal compromise, central, foraminal, disc, spineNOTE,: 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 MRI interpretation indicates mild degenerative changes and some specific areas of concern, such as disc protrusion and nerve root impingement. However, there are no high-grade central canal or foraminal stenoses, which suggests that while these findings may require medical attention to prevent worsening and manage symptoms, they are not immediately life-threatening. Consequently, the findings are not considered high-stakes in terms of requiring urgent intervention for a critical or life-threatening condition.


Medical Specialty: Surgery
Sample Name: Thoracic Discectomy

PREOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus T8-T9.,POSTOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus T8-T9.,OPERATION PERFORMED: , Thoracic right-sided discectomy at T8-T9.,BRIEF HISTORY AND INDICATION FOR OPERATION: , The patient is a 53-year-old female with a history of right thoracic rib pain related to a herniated nucleus pulposus at T8-T9.  She has failed conservative measures and sought operative intervention for relief of her symptoms.  For details of workup, please see the dictated operative report.,DESCRIPTION OF OPERATION:  ,Appropriate informed consent was obtained and the patient was taken to the operating room and placed under general anesthetic.  She was placed in a position of comfort on the operating table with all bony prominences and soft tissues well padded and protected.  Second check was made prior to prepping and draping.  Following this, we did needle localization with reviews of AP and lateral multiple times to make sure we had the T8-T9 level.  We then made an approach through a midline incision and came out over the pars.  We dissected down carefully to identify the pars.  We then went on the outside of the pars and identified the foramen and then we took another series of x-rays to confirm the T8-T9 level.  We did this under live fluoroscopy.  We confirmed T8-T9 and then went ahead and took a Midas Rex and removed the superior portion of the pedicle overlying the outside of the disc and then worked our way downward removing portion of the transverse process as well.  We found the edge of the disc and then worked our way and we were able to remove some of the disc material but then decided to go ahead and take down the pars.  The pars was then drilled out.  We identified the disc even further and found the disc herniation material that was under the spinal cord.  We then took a combination of small pituitaries and removed the disc material without difficulty.  Once we had disc material out, we went ahead and made a small cruciate incision in the disc space and entered the disc space in earnest removing more disc material making sure there is nothing free to herniate further.  Once we had done that, we inspected up by the nerve root, found some more disc material there and removed that as well.  We could trace the nerve root out freely and easily.  We made sure there was no evidence of further disc material.  We used an Epstein curette and placed a nerve hook under the nerve root.  The Epstein curette removed some more disc material.  Once we had done this, we were satisfied with the decompression.  We irrigated the wound copiously to make sure there is no further disc material and then ready for closure.  We did place some steroid over the nerve root and readied for closure.  Hemostasis was meticulous.  The wound was closed with #1 Vicryl suture for the fascial layer, 2 Vicryl suture for the skin, and Monocryl and Steri-Strips applied.  Dressing was applied.  The patient was awoken from anesthesia and taken to the recovery room in stable condition.,ESTIMATED BLOOD LOSS:,  150 mL.,COMPLICATIONS: , None.,DISPOSITION:,  To PACU in stable condition having tolerated the procedure well, to mobilize routinely when she is comfortable to go to her home.
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DESCRIPTION: Thoracic right-sided discectomy at T8-T9.   The patient is a 53-year-old female with a history of right thoracic rib pain related to a herniated nucleus pulposus at T8-T9.

surgery, thoracic right-sided discectomy, herniated nucleus pulposus, discectomy, thoracic, herniated,

A thoracic discectomy is a surgical procedure to remove part of a herniated disc in the thoracic spine, which can be high-stakes due to its proximity to critical structures such as the spinal cord. The preoperative and postoperative diagnosis confirms the presence of a herniated disc at the T8-T9 level, which can cause significant pain and potentially lead to neurological deficits if not treated. Surgery involving the spine requires precision and has inherent risks such as nerve damage, infection, or bleeding. Despite the patient having no complications in this scenario, the nature of the procedure still involves potential life-altering stakes and medical risks. Therefore, this situation is considered high-stakes.


Medical Specialty: Ophthalmology
Sample Name: Ophthalmology Progress Note - 2

A fluorescein angiogram was ordered at today's visit to rule out macular edema.  We have asked her to return in one to two weeks' time to discuss the results of her angiogram and possible intervention and will be sure to keep you apprised of her ongoing progress.  A copy of the angiogram is enclosed for your records.
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DESCRIPTION: Ophthalmology followup visit note.

Ophthalmology followup visit note.

ophthalmology, visual acuities, 78-diopter lens, extraocular muscle movement, afferent, angiogram, applanation, detachment, dilated fundus examination, fluorescein, hemorrhages, intraocular, intraocular lenses, left eye, posterior chamber, pupillary, retinopathy, right eye, slit-lamp, lensesNOTE,: 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 follow-up ophthalmology visit where the results of a fluorescein angiogram are pending to rule out macular edema. Macular edema can lead to vision impairment, which is a significant health concern, especially if left untreated. However, this visit seems to be routine monitoring rather than addressing any immediate symptoms or complications. Since the patient is to return in one to two weeks for a discussion about the results and possible interventions, this suggests that the situation is being handled proactively but not urgently. Therefore, while there is potential for serious outcomes if not managed properly, the current task is a part of standard medical care with no immediate signs of critical urgency.