Medical Specialty: Gastroenterology
Sample Name: Esophagogastroduodenoscopy - 9

PREOPERATIVE DIAGNOSES: , Malnutrition and dysphagia.,POSTOPERATIVE DIAGNOSES: , Malnutrition and dysphagia with two antral polyps and large hiatal hernia.,PROCEDURES: , Esophagogastroduodenoscopy with biopsy of one of the polyps and percutaneous endoscopic gastrostomy tube placement.,ANESTHESIA: , IV sedation, 1% Xylocaine locally.,CONDITION:,  Stable.,OPERATIVE NOTE IN DETAIL: , After risk of operation was explained to this patient's family, consent was obtained for surgery.  The patient was brought to the GI lab.  There, she was placed in partial left lateral decubitus position.  She was given IV sedation by Anesthesia.  Her abdomen was prepped with alcohol and then Betadine.  Flexible gastroscope was passed down the esophagus, through the stomach into the duodenum.  No lesions were noted in the duodenum.  There appeared to be a few polyps in the antral area, two in the antrum.  Actually, one appeared to be almost covering the pylorus.  The scope was withdrawn back into the antrum.  On retroflexion, we could see a large hiatal hernia.  No other lesions were noted.  Biopsy was taken of one of the polyps.  The scope was left in position.  Anterior abdominal wall was prepped with Betadine, 1% Xylocaine was injected in the left epigastric area.  A small stab incision was made and a large bore Angiocath was placed directly into the anterior abdominal wall, into the stomach, followed by a thread, was grasped with a snare using the gastroscope, brought out through the patient's mouth.  Tied to the gastrostomy tube, which was then pulled down and up through the anterior abdominal wall.  It was held in position with a dressing and a stent.  A connector was applied to the cut gastrostomy tube, held in place with a 2-0 silk ligature.  The patient tolerated the procedure well.  She was returned to the floor in stable condition.
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DESCRIPTION: Esophagogastroduodenoscopy with biopsy of one of the polyps and percutaneous endoscopic gastrostomy tube placement.  Malnutrition and dysphagia with two antral polyps and large hiatal hernia.

gastroenterology, antral, polyps, gastrostomy, endoscopic gastrostomy, hiatal hernia, abdominal wall, gastrostomy tube, esophagogastroduodenoscopy, malnutrition, dysphagia, abdominal

The procedure described is an esophagogastroduodenoscopy with biopsy and percutaneous endoscopic gastrostomy tube placement, performed to manage malnutrition and dysphagia, likely due to the antral polyps and large hiatal hernia. Although the patient is stable post-operatively and the procedure went as planned, the stakes are inherently high because the procedure involves multiple factors that directly relate to the patient's ability to intake nutrition, which is critical given the diagnosis of malnutrition. The procedure also involves sedation and invasive endoscopy, which carry inherent risks. Additionally, explaining the procedure's risks to the family and obtaining their consent indicates the procedure's significance. However, it's not a life-or-death situation at this immediate moment, which lowers the stakes slightly.


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

Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Mayoview - 1

MYOVIEW NUCLEAR STRESS STUDY,REASON FOR THE TEST:,  Angina, coronary artery disease.,FINDINGS: , The patient exercised according to the Lexiscan nuclear stress study, received a total of 0.4 mg of Lexiscan.  At peak hyperemic effect, 25.8 mCi of Myoview injected for the stress imaging and earlier 8.1 mCi of Myoview injected for the resting and the usual SPECT and gated SPECT protocol was followed in the rest-stress sequence.,The data analyzed using Cedars-Sinai software.,The resting heart rate was 49 with the resting blood pressure of 149/86.  Maximum heart rate achieved was 69 with a maximum blood pressure achieved of 172/76.,EKG at rest showed to be abnormal with sinus rhythm, left atrial enlargement, and inverted T-wave in 1, 2, and aVL as well as from V4 to V6 with LVH.  Maximal stress test EKG showed no change from baseline.,IMPRESSION:  ,Maximal Lexiscan stress test with abnormal EKG at baseline maximal stress test, please refer to the Myoview interpretation.,MYOVIEW INTERPRETATIONS,FINDINGS: , The left ventricle appears to be dilated on both stress and rest with no significant change between stress and rest with left ventricular end-diastolic volume of 227, end-systolic volume of 154 with moderately to severely reduced LV function with akinesis of the inferior and inferoseptal wall.  EF was calculated at 32%, estimated 35% to 40%.,Cardiac perfusion reviewed, showed a large area of moderate-to-severe intensity in the inferior wall and small-to-medium area of severe intensity at the apex and inferoapical wall.  Both defects showed no change on the resting indicative of a fixed defect in the inferior and inferoapical wall consistent with old inferior inferoapical MI.  No reversible defects indicative of myocardium at risk.  The lateral walls as well as the septum and most of the anterior wall showed no reversibility and near-normal perfusion.,IMPRESSION:,1.  Large fixed defect, inferior and apical wall, related to old myocardial infarction.,2.  No reversible ischemia identified.,3.  Moderately reduced left ventricular function with ejection fraction of about 35% consistent with ischemic cardiomyopathy.
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DESCRIPTION: Myoview nuclear stress study.  Angina, coronary artery disease.  Large fixed defect, inferior and apical wall, related to old myocardial infarction.

cardiovascular / pulmonary, myoview, myoview interpretations, spect, gated spect protocol, myoview nuclear stress study, nuclear stress study, stress study, stress test, stress, lexiscan, ekg, inferoapical, angina, wall, resting,

The Myoview nuclear stress study reveals several critical findings, such as a large fixed defect related to an old myocardial infarction, moderately reduced left ventricular function, and an abnormal EKG. These findings suggest the patient has significant cardiovascular issues that can heavily impact their health if not managed properly. The potential for worsening heart conditions or sudden cardiac events further heightens the stakes of the situation, impacting medical decision-making and patient outcomes.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: ENT - Otolaryngology
Sample Name: Tonsillectomy and Septoplasty

PREOPERATIVE DIAGNOSIS:,  Obstructive sleep apnea syndrome with hypertrophy of tonsils and of uvula and soft palate.,POSTOPERATIVE DIAGNOSIS:,  Obstructive sleep apnea syndrome with hypertrophy of tonsils and of uvula and soft palate with deviation of nasal septum.,OPERATION:,  Tonsillectomy, uvulopalatopharyngoplasty, and septoplasty.,ANESTHESIA:,  General anesthetics.,HISTORY: , This is a 51-year-old gentleman here with his wife.  She confirms the history of loud snoring at night with witnessed apnea.  The result of the sleep study was reviewed.  This showed moderate sleep apnea with significant desaturation.  The patient was unable to tolerate treatment with CPAP.  At the office, we observed large tonsils and elongation and thickening of the uvula as well as redundant soft tissue of the palate.  A tortuous appearance of the septum also was observed.  This morning, I talked to the patient and his wife about the findings.  I reviewed the CT images.  He has no history of sinus infections and does not recall a history of nasal trauma.  We discussed the removal of tonsils and uvula and soft palate tissue and the hope that this would help with his airway.  Depending on the findings of surgery, I explained that I might remove that bone spur that we are seeing within the nasal passage.  I will get the best look at it when he is asleep.  We discussed recovery as well.  He visited with Dr. XYZ about the anesthetic produce.,PROCEDURE:,:  General tracheal anesthetic was administered by Dr. XYZ and Mr. Radke.  Afrin drops were placed in both nostrils and a cottonoid soaked with Afrin was placed in each side of the nose.  A Crowe-Davis mouth gag was placed.  The tonsils were very large and touched the uvula.  The uvula was relatively long and very thick and there were redundant folds of soft palate mucosa and prominent posterior and anterior tonsillar pillars.  Also, there was a cryptic appearance of the tonsils but there was no acute redness or exudate.  Retraction of the soft palate permitted evaluation of the nasopharynx with the mirror and the choanae were patent and there was no adenoid tissue present.  A very crowded pharynx was appreciated.  The tonsils were first removed using electrodissection technique.  Hemostasis was achieved with the electrocautery and with sutures of 0 plain catgut.  The tonsil fossae were injected with 0.25% Marcaine with 1:200,000 epinephrine.  There already was more room in the pharynx, but the posterior pharyngeal wall was still obscured by the soft palate and uvula.  The uvula was grasped with the Alice clamp.  I palpated the posterior edge of the hard palate and calculated removal of about a third of the length of the soft palate.  We switched over from the Bayonet cautery to the blunt needle tip electrocautery.  The planned anterior soft palate incision was marked out with the electrocautery from the left anterior tonsillar pillar rising upwards and then extending horizontally across the soft palate to include all of the uvula and a portion of the soft palate, and the incision then extended across the midline and then inferiorly to meet the right anterior tonsillar pillar.  This incision was then deepened with the electrocautery on a cutting current.  The uvular artery just to the right of the midline was controlled with the suction electrocautery.  The posterior soft palate incision was made parallel to the anterior soft palate incision but was made leaving a longer length of mucosa to permit closure of the palatoplasty.  A portion of the redundant soft palate mucosa tissue also was included with the resection specimen and the tissue including the soft palate and uvula was included with the surgical specimen as the tonsils were sent to pathology.  The tonsil fossae were injected with 0.25% Marcaine with 1:200,000 epinephrine.  The soft palate was also injected with 0.25% Marcaine with 1:200,000 epinephrine.  The posterior tonsillar pillars were then brought forward to close to the anterior tonsillar pillars and these were sutured down to the tonsil bed with interrupted 0 plain catgut sutures.  The posterior soft palate mucosa was advanced forward and brought up to the anterior soft palate incision and closure of the soft palate wound was then accomplished with interrupted 3-0 chromic catgut sutures.  A much improved appearance of the oropharynx with a greatly improved airway was appreciated.  A moist tonsil sponge was placed into the nasopharynx and the mouth gag was removed.  I removed the cottonoids from both nostrils.  Speculum exam showed the inferior turbinates were large, the septum was tortuous and it angulated to the right and then sharply bent back to the left.  The septum was injected with 0.25% Marcaine with 1:200,000 epinephrine using a separate syringe and needle.  A #15 blade was used to make a left cheilion incision.,Mucoperichondrium and mucoperiosteum were elevated with the Cottle elevator.  When we reached the deflected portion of the vomer, this was separated from the septal cartilage with a Freer elevator.  The right-sided mucoperiosteum was elevated with the Freer elevator and then with Takahashi forceps and with the 4 mm osteotome, the deflected portion of the septal bone from the vomer was resected.  This tissue also was sent as a separate specimen to pathology.  The intraseptal space was irrigated with saline and suctioned.  The nasal septal mucosal flaps were then sutured together with a quilting suture of 4-0 plain catgut.  I observed no evidence of purulent secretion or polyp formation within the nostrils.  The inferior turbinates were then both outfractured using a knife handle, and now there was a much more patent nasal airway on both sides.  There was good support for the nasal tip and the dorsum and there was good hemostasis within the nose.  No packing was used in the nostrils.  Polysporin ointment was introduced into both nostrils.  The mouth gag was reintroduced and the pack removed from the nasopharynx.  The nose and throat were irrigated with saline and suctioned.  An orogastric tube was placed and a moderate amount of clear fluid suctioned from the stomach and this tube was removed.  Sponge and needle count were reported correct.  The mouth gag having been withdrawn, the patient was then awakened and returned to recovery room in a satisfactory condition.  He tolerated the operation excellently.  Estimated blood loss was about 15-20 cc.  In the recovery room, I observed that he was moving air well and I spoke with his wife about the findings of surgery.
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DESCRIPTION: Tonsillectomy, uvulopalatopharyngoplasty, and septoplasty for obstructive sleep apnea syndrome with hypertrophy of tonsils and of uvula and soft palate with deviation of nasal septum

ent - otolaryngology, obstructive sleep apnea syndrome, afrin drops, bayonet cautery, cpap, cottle elevator, crowe-davis, freer elevator, obstructive sleep apnea, tonsillectomy, hypertrophy, mouth gag, nasal, nasal passage, nasal septum, nasopharynx, nostrils, palate, pharynx, septal cartilage, septoplasty, sleep apnea, soft palate, tonsils, uvula, uvulopalatopharyngoplasty, hypertrophy of tonsils, anterior tonsillar pillars, soft palate incision, palate incision, tonsillar pillars, incision

The situation described is a medical procedure involving tonsillectomy, uvulopalatopharyngoplasty, and septoplasty aimed at addressing obstructive sleep apnea. This is a high-stakes situation given it involves surgery under general anesthesia, which always carries inherent risks such as reactions to anesthesia, bleeding, infection, and other complications. Moreover, the procedure is meant to improve a significant health condition (obstructive sleep apnea) that can greatly affect the patient's quality of life and overall health if untreated. While the surgery appears to have been conducted successfully, the nature of the procedure and the use of general anesthesia make it a high-stakes situation to ensure the patient's safety and the operation’s success.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Transesophageal Echocardiogram - 1

INDICATION: , Aortic stenosis.,PROCEDURE: , Transesophageal echocardiogram.,INTERPRETATION:  ,Procedure and complications explained to the patient in detail.  Informed consent was obtained.  The patient was anesthetized in the throat with lidocaine spray.  Subsequently, 3 mg of IV Versed was given for sedation.  The patient was positioned and transesophageal probe was introduced without any difficulty.  Images were taken.  The patient tolerated the procedure very well without any complications.  Findings as mentioned below.,FINDINGS:,1.  Left ventricle is in normal size and dimension.  Normal function.  Ejection fraction of 60%.,2.  Left atrium and right-sided chambers are of normal size and dimension.,3.  Mitral, tricuspid, and pulmonic valves are structurally normal.,4.  Aortic valve reveals annular calcification with fibrocalcific valve leaflets with decreased excursion.,5.  Left atrial appendage is clean without any clot or smoke effect.,6.  Atrial septum intact.  Study was negative.,7.  Doppler study essentially benign.,8.  Aorta essentially benign.,9.  Aortic valve planimetry valve area average about 1.3 cm2 consistent with moderate aortic stenosis.,SUMMARY:,1.  Normal left ventricular size and function.,2.  Benign Doppler flow pattern.,3.  Aortic valve area of 1.3 cm2 planimetry.,
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DESCRIPTION: Transesophageal echocardiogram for aortic stenosis.  Normal left ventricular size and function.  Benign Doppler flow pattern.   Doppler study essentially benign.  Aorta essentially benign.  Atrial septum intact.  Study was negative.

cardiovascular / pulmonary, aortic valve, ejection fraction, planimetry, ventricular, transesophageal, echocardiogram, atrial septum, septum intact, transesophageal echocardiogram, aortic stenosis, doppler, aortic, valves

The situation involves a transesophageal echocardiogram, which is a procedure used to assess the heart, specifically for aortic stenosis. While the procedure itself can have risks, this report indicates that the procedure was completed without complications, and the findings are largely benign except for moderate aortic stenosis. Since the patient tolerated the procedure well and there were no immediate risks or complications, the situation is not highly urgent or life-threatening at the moment. However, it does involve a chronic cardiovascular condition which typically requires ongoing medical attention.


Medical Specialty: Gastroenterology
Sample Name: Cholecystostomy Tube Placement

PREOPERATIVE DIAGNOSIS:,  Acute acalculous cholecystitis.,POSTOPERATIVE DIAGNOSIS: , Acute acalculous cholecystitis.,PROCEDURE:,  Placement of cholecystostomy tube under ultrasound guidance.,ANESTHESIA: , Xylocaine 1% With Epinephrine.,INDICATIONS: , Patient is a pleasant 75-year-old gentleman who is about one week status post an acute MI who also has acute cholecystitis.  Because it is not safe to take him to the operating room for general anesthetic, I recommended he undergo the above-named procedure.  Procedure, purpose, risks, expected benefits, potential complications, and alternative forms of therapy were discussed with him and he was agreeable to surgery.,TECHNIQUE: , Patient was identified, then taken to the Radiology suite, where the area of interest was identified using ultrasound and prepped with Betadine solution, draped in sterile fashion.  After infiltration with 1% Xylocaine and after multiple attempts, the gallbladder was finally cannulated by Dr. Kindred using the Cook 18-French needle.  The guidewire was then placed and via Seldinger technique, a 10-French pigtail catheter was placed within the gallbladder, secured using the Cook catheter method, and dressings were applied and patient was taken to recovery room in stable condition.
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DESCRIPTION: Placement of cholecystostomy tube under ultrasound guidance.  Acute acalculous cholecystitis.

gastroenterology, under ultrasound guidance, cholecystostomy tube, acalculous cholecystitis, catheter, cholecystostomy, ultrasound, acalculous, cholecystitis

This cholecystostomy procedure is performed on a high-risk patient with recent acute myocardial infarction (MI) and acute cholecystitis. The stakes are considerable because the patient's condition prevents the use of general anesthesia, which increases the complexity and potential risks of the procedure. Furthermore, acute acalculous cholecystitis can lead to severe complications if not treated promptly and effectively. While the procedure itself is less invasive compared to surgical alternatives, it still carries risk, particularly in a context of already compromised patient health. However, the procedure went as planned, and the patient was stable post-operation, indicating that the immediacy of the stakes may not be extremely high but significant due to the patient's overall condition.


Medical Specialty: Orthopedic
Sample Name: Carpal Tunnel Release - 2

PREOPERATIVE DIAGNOSIS: , Left carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS: , Left carpal tunnel syndrome.,OPERATIVE PROCEDURE:,1.  Left endoscopic carpal tunnel release.,2.  Endotracheal fasciotomy.,ANESTHESIA:,  General.,COMPLICATIONS: , None.,INDICATION: , The patient is a 62-year-old lady with the aforementioned diagnosis refractory to nonoperative management.  All risks and benefits were explained.  Questions answered.  Options discussed.  No guarantees were made.  She wished to proceed with surgery.,PROCEDURE: , After administering appropriate antibiotics and MAC anesthesia, the upper extremity was prepped and draped in the usual standard fashion, the arm was exsanguinated with Esmarch, and the tourniquet inflated to 250 mmHg.,I made a transverse incision one fingerbreadth proximal to the distal volar wrist crease.  Dissection was carried down to the antebrachial fascia, which was cut in a distally based fashion.  Bipolar electrocautery was used to maintain meticulous hemostasis.  I then performed an antebrachial fasciotomy proximally.  I entered the extra bursal space deep into the transverse carpal ligament and used the spatula probe and then the dilators and then the square probe to enlarge the area.  Great care was taken to feel the washboard undersurface of the transverse carpal ligament and the hamate on the ulnar side.  Great care was taken with placement.  A good plane was positively identified.  I then placed the endoscope in and definitely saw the transverse striations of the deep surface of the transverse carpal ligament.,Again, I felt the hook of the hamate ulnar to me.  I had my thumb on the distal aspect of the transverse carpal ligament.  I then partially deployed the blade, and starting 1 mm from the distal edge, the transverse carpal ligament was positively identified.  I pulled back and cut and partially tightened the transverse carpal ligament.  I then feathered through the distal ligament and performed a full-thickness incision through the distal half of the ligament.  I then checked to make sure this was properly performed and then cut the proximal aspect.  I then entered the carpal tunnel again and saw that the release was complete, meaning that the cut surfaces of the transverse carpal ligament were separated; and with the scope rotated, I could see only one in the field at a time.  Great care was taken and at no point was there any longitudinal structure cut.  Under direct vision through the incision, I made sure that the distal antebrachial fascia was cut.  Following this, I irrigated and closed the skin.  The patient was dressed and sent to the recovery room in good condition.
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DESCRIPTION: Left endoscopic carpal tunnel release and endotracheal fasciotomy.

orthopedic, carpal tunnel syndrome, antebrachial fascia, antebrachial fasciotomy, carpal tunnel release, electrocautery, fasciotomy, hamate, wrist crease, endoscopic carpal tunnel release, transverse carpal ligament, carpal tunnel, transverse carpal, carpal ligament, carpal, antebrachial, transverse, ligament

The situation involves a surgical procedure known as a carpal tunnel release with the added complexity of an endotracheal fasciotomy. Although carpal tunnel release is a common and generally low-risk surgery, it still involves general anesthesia and surgical intervention, which inherently carry certain risks. Potential complications, though none occurred in this case, can include infection, nerve damage, or issues related to anesthesia. The fact that the patient is undergoing surgery implies a degree of seriousness. However, the lack of complications and the routine nature of the procedure suggest this is not an extremely high-stakes situation.


Medical Specialty: Gastroenterology
Sample Name: Colonoscopy - 9

PREOPERATIVE DIAGNOSIS:,  Prior history of polyps.,POSTOPERATIVE DIAGNOSIS:,  Small polyps, no evidence of residual or recurrent polyp in the cecum.,PREMEDICATIONS: , Versed 5 mg, Demerol 100 mg IV.,REPORTED PROCEDURE:,  The rectal chamber revealed no external lesions.  Prostate was normal in size and consistency.,The colonoscope was inserted into the rectal ampulla and advanced under direct vision at all times until the tip of the scope was placed in the cecum.  The position of the scope within the cecum was verified by identification of the ileocecal valve.  Navigation was difficult because it seemed that the cecum took an upward turn at its final turn, but the examination was completed.,The cecum was extensively studied and no lesion was seen.  There was not even a scar representing the prior polyp.  I was able to see the area across from the ileocecal valve exactly where the polyp was two years ago, and I saw no lesion at all.  The scope was then slowly withdrawn.  In the mid transverse colon, was a small submucosal lesion, which appeared to be a lipoma.  It was freely mobile and very small with normal overlying mucosa.  There was a similar lesion in the descending colon.  Both of these appeared to be lipomatous, so no attempt was made to remove them.  There were diverticula present in the sigmoid colon.  In addition, there were two polyps in the sigmoid colon both of which were resected using electrocautery.  There was no bleeding.  The scope was then withdrawn.  The rectum was normal.  When the scope was retroflexed in the rectum, two very small polyps were noted just at the anorectal margin, and so these were obliterated using the electrocautery snare.  There was no specimen and there was no bleeding.  The scope was then straightened, withdrawn, and the procedure terminated.,ENDOSCOPIC IMPRESSION:,1.  Small polyps, sigmoid colon, resected them.,2.  Diverticulosis, sigmoid colon.,3.  Small rectal polyps, obliterated them.,4.  Submucosal lesions, consistent with lipomata as described.,5.  No evidence of residual or recurrent neoplasm in the cecum.
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DESCRIPTION: Patient with history of polyps.

Patient with history of polyps.

gastroenterology, ileocecal valve, sigmoid colon, polyps, ileocecal, submucosal, electrocautery, bleeding, rectum, rectal, sigmoid, cecum, scope, colonoscopy,

The procedure involves the detection and removal of polyps during a colonoscopy, which is a routine but essential process in preventing potential progression to colorectal cancer. The findings showed small polyps which were resected, but there was no evidence of neoplasm or significant issues requiring immediate action. The situation is important for patient care but is considered low-stakes since the procedure was completed successfully without complications, and the findings were not indicative of a severe or immediate health threat.


Medical Specialty: Gastroenterology
Sample Name: Colonoscopy - 16

PROCEDURE: , Colonoscopy.,PREOPERATIVE DIAGNOSES: , Rectal bleeding and perirectal abscess.,POSTOPERATIVE DIAGNOSIS: , Perianal abscess.,MEDICATIONS:,  MAC.,DESCRIPTION OF PROCEDURE:  ,The Olympus pediatric variable colonoscope was introduced through the rectum and advanced carefully through the colon into the cecum and then through the ileocecal valve into the terminal ileum.  The preparation was excellent and all surfaces were well seen.  The mucosa throughout the colon and in the terminal ileum was normal, with no evidence of colitis.  Special attention was paid to the rectum, including retroflexed views of the distal rectum and the anorectal junction.  There was no evidence of either inflammation or a fistulous opening.  The scope was withdrawn.  A careful exam of the anal canal and perianal area demonstrated a jagged 8-mm opening at the anorectal junction posteriorly (12 o'clock position).  Some purulent material could be expressed through the opening.  There was no suggestion of significant perianal reservoir of inflamed tissue or undrained material.  Specifically, the posterior wall of the distal rectum and anal canal were soft and unremarkable.  In addition, scars were noted in the perianal area.  The first was a small dimpled scar, 1 cm from the anal verge in the 11 o'clock position.  The second was a dimpled scar about 5 cm from the anal verge on the left buttock's cheek.  There were no other abnormalities noted.  The patient tolerated the procedure well and was sent to the recovery room.,FINAL DIAGNOSES:,1.  Normal colonoscopy to the terminal ileum.,2.  Opening in the skin at the external anal verge, consistent with drainage from a perianal abscess, with no palpable abscess at this time, and with no evidence of fistulous connection to the bowel lumen.,RECOMMENDATIONS:,1.  Continue antibiotics.,2.  Followup with Dr. X.,3.  If drainage persists, consider surgical drainage.
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DESCRIPTION: Colonoscopy.   Rectal bleeding and perirectal abscess.  Normal colonoscopy to the terminal ileum.  Opening in the skin at the external anal verge, consistent with drainage from a perianal abscess, with no palpable abscess at this time, and with no evidence of fistulous connection to the bowel lumen.

gastroenterology, olympus, colonoscope, rectal bleeding, perianal abscess, terminal ileum, anal verge, anorectal, fistulous, ileum, verge, rectum, anal, perianal, colonoscopy, abscess

The scenario involves a colonoscopy procedure due to symptoms like rectal bleeding and a perirectal abscess. The procedure revealed an opening consistent with drainage from a perianal abscess, but no significant complications such as a fistula or additional abscesses were found. The condition is not immediately life-threatening but needs monitoring and possibly more surgical intervention if symptoms persist. Thus, while it requires medical attention and follow-up, it's not an extremely high-stakes situation.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Mesothelioma - Pleural Biopsy

PREOPERATIVE DIAGNOSIS: , Right pleural effusion and suspected malignant mesothelioma.,POSTOPERATIVE DIAGNOSIS:,  Right pleural effusion, suspected malignant mesothelioma.,PROCEDURE: , Right VATS pleurodesis and pleural biopsy.,ANESTHESIA:,  General double-lumen endotracheal.,DESCRIPTION OF FINDINGS: , Right pleural effusion, firm nodules, diffuse scattered throughout the right pleura and diaphragmatic surface.,SPECIMEN: , Pleural biopsies for pathology and microbiology.,ESTIMATED BLOOD LOSS: , Minimal.,FLUIDS: , Crystalloid 1.2 L and 1.9 L of pleural effusion drained.,INDICATIONS: , Briefly, this is a 66-year-old gentleman who has been transferred from an outside hospital after a pleural effusion had been drained and biopsies taken from the right chest that were thought to be consistent with mesothelioma.  Upon transfer, he had a right pleural effusion demonstrated on x-ray as well as some shortness of breath and dyspnea on exertion.  The risks, benefits, and alternatives to right VATS pleurodesis and pleural biopsy were discussed with the patient and his family and they wished to proceed.,PROCEDURE IN DETAIL:  ,After informed consent was obtained, the patient was brought to the operating room and placed in supine position.  A double-lumen endotracheal tube was placed.  SCDs were also placed and he was given preoperative Kefzol.  The patient was then brought into the right side up, left decubitus position, and the area was prepped and draped in the usual fashion.  A needle was inserted in the axillary line to determine position of the effusion.  At this time, a 10-mm port was placed using the knife and Bovie cautery.  The effusion was drained by placing a sucker into this port site.  Upon feeling the surface of the pleura, there were multiple firm nodules.  An additional anterior port was then placed in similar fashion.  The effusion was then drained with a sucker.  Multiple pleural biopsies were taken with the biopsy device in all areas of the pleura.  Of note, feeling the diaphragmatic surface, it appeared that it was quite nodular, but these nodules felt as though they were on the other side of the diaphragm and not on the pleural surface of the diaphragm concerning for a possibly metastatic disease.  This will be worked up with further imaging study later in his hospitalization.  After the effusion had been drained, 2 cans of talc pleurodesis aerosol were used to cover the lung and pleural surface with talc.  The lungs were then inflated and noted to inflate well.  A 32 curved chest tube chest tube was placed and secured with nylon.  The other port site was closed at the level of the fascia with 2-0 Vicryl and then 4-0 Monocryl for the skin.  The patient was then brought in the supine position and extubated and brought to recovery room in stable condition.,Dr. X was present for the entire procedure which was right VATS pleurodesis and pleural biopsies.,The counts were correct x2 at the end of the case.
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DESCRIPTION: Right pleural effusion and suspected malignant mesothelioma.

cardiovascular / pulmonary, double-lumen, endotracheal, pleural surface, chest tube, pleural biopsy, malignant mesothelioma, vats pleurodesis, pleural biopsies, pleural effusion, pleural, vats, pleurodesis, mesothelioma,

The situation described involves a medical procedure for a patient with suspected malignant mesothelioma, which is a severe and potentially life-threatening condition due to its aggressive nature and poor prognosis. The procedure itself, right VATS pleurodesis and pleural biopsy, is invasive and carries typical surgical risks. Additionally, the possibility of metastatic disease further increases the stakes. Therefore, this situation involves significant health implications for the patient and requires careful clinical management and follow-up.


Medical Specialty: Pain Management
Sample Name: Transforaminal Epidural Steroid Injection - 1

PROCEDURE:  ,Transforaminal Epidural, lumbar.,INFORMED CONSENT: , The risks, benefits and alternatives of the procedure were discussed with the patient.  The patient was given opportunity to ask questions regarding the procedure, its indications and the associated risks.,The risk of the procedure discussed include infection, bleeding, allergic reaction, dural puncture, headache, nerve injuries, spinal cord injury, and cardiovascular and CNS side effects with possible of vascular entry of medications.  I also informed the patient of potential side effects or reactions to the medications potentially used during the procedure including sedatives, narcotics, nonionic contrast agents, anesthetics, and corticosteroids.,The patient was informed both verbally and in writing.  The patient understood the informed consent and desired to have the procedure performed.,PROCEDURE: , Oxygen saturation and vital signs were monitored continuously throughout the procedure.  The patient remained awake throughout the procedure in order to interact and give feedback.  The X-ray technician was supervised and instructed to operate the fluoroscopy machine.,The patient was placed in the prone position on the treatment table with a pillow under the lower abdomen to reduce the natural lumbar lordosis.  The skin over and surrounding the treatment area was cleaned with betadine.  The area was covered with sterile drapes, leaving a small window opening for needle placement.  Fluoroscopy was used to identify the boney landmarks of the facet joints and the planned needle approach.  The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1 % lidocaine.,With fluoroscopy, a *** spinal needle was gently guided into the superior-anterior neuroforamin lateral to the mid-pedicular line at ***.  Multiple fluoroscopic views were used to ensure proper needle placement.  Approximately *** of non-ionic contrast agent was injected into the joint under real time fluoroscopic observation.  Correct needle placement was confirmed by production of an appropriate epidurogram and radiculogram without concurrent vascular dye pattern.  Finally the treatment solution, consisting of *** was injected.,All injected medications were preservative free.  Sterile techniques were used throughout the procedure.,COMPLICATIONS:  ,None.  No complications.,The patient tolerated the procedure well and was sent to the recovery room in good condition.,DISCUSSION: , Post-procedure vital signs and oximetry were stable.  The patient was discharged with instructions to ice the injection site as needed for 15-20 minutes as frequently as twice per hour for the next day and to avoid aggressive activities for 1 day.  The patient was told to resume all medications.  The patient was told to be in relative rest for 1 day but then could resume all normal activities.,The patient was instructed to seek immediate medical attention for shortness of breath, chest pain, fever, chills, increased pain, weakness, sensory or motor changes, or changes in bowel or bladder function.,Follow up appointment was made in approximately 1 week.
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DESCRIPTION: Transforaminal Epidural, lumbar - Template.  Fluoroscopy was used to identify the boney landmarks of the facet joints and the planned needle approach.  The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1 % lidocaine.

pain management, epidural lumbar, facet joints, transforaminal epidural, injection, transforaminal, epidural, lumbar, fluoroscopy, needle,

The procedure, a transforaminal epidural steroid injection, is a common minimally invasive technique used in pain management, often for providing relief from conditions like lumbar radiculopathy. It is not considered a major surgical procedure, but it involves some inherent risks such as infection, bleeding, nerve damage, and reactions to medications. These risks necessitate informed consent and precise execution. Although there are safeguards in place such as monitoring and the use of sterile techniques, the potential for complications, while minimal, still exists. This makes it moderately high-stakes as it requires careful handling but generally has a low incidence of serious complications.


Medical Specialty: Discharge Summary
Sample Name: Hemiarthroplasty - Discharge Summary

ADMISSION DIAGNOSES:  ,Fracture of the right femoral neck, also history of Alzheimer's dementia, and hypothyroidism.,DISCHARGE DIAGNOSES: , Fracture of the right femoral neck, also history of Alzheimer's dementia, hypothyroidism, and status post hemiarthroplasty of the hip.,PROCEDURE PERFORMED:  ,Hemiarthroplasty, right hip.,CONSULTATIONS:  ,Medicine for management of multiple medical problems including Alzheimer's.,HOSPITAL COURSE: , The patient was admitted on 08/06/2007 after a fall with subsequent fracture of the right hip.  The patient was admitted to Orthopedics and consulted Medicine.  The patient was actually taken to the operating room, consent signed by durable power of attorney, taken on 08/06/2007, had right hip hemiarthroplasty, recovered without incidence.  The patient had continued confusion and dementia, which is apparently his baseline secondary to his Alzheimer's.  Brief elevation of white count following the surgery, which did subside.  Studies, UA and blood culture were negative.  The patient was stable and was discharged to Heartland.,CONDITION ON DISCHARGE: , Stable.,DISCHARGE INSTRUCTIONS:,  Transfer to ABC for rehab and continued care.  Diabetic diet.  Activity, ambulate as tolerated with posterior hip precautions.  Rehab potential fair.  He will need nursing, Social Work, PT/OT, and nutrition consults.  Resume home meds, DVT prophylaxis, aspirin, and compression stockings.  Follow up Dr. X in one to two weeks; call 123-4567 for an appointment.
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DESCRIPTION: Hemiarthroplasty, right hip.  Fracture of the right femoral neck, also history of Alzheimer's dementia, hypothyroidism, and status post hemiarthroplasty of the hip.

discharge summary, femoral neck, orthopedics, rehab, femoral, neck, fracture, dementia, hemiarthroplasty, hip,

The discharge summary provided is a routine medical document outlining the patient's condition and treatment plan following surgery. While it involves important medical considerations, such as post-operative care and management of dementia, it reflects standard hospital discharge instructions and follow-up care rather than an emergency or life-threatening situation. The stakes are moderate due to the patient's multiple conditions and need for rehabilitation, but not extremely high since the patient is stable and the surgery was without incidence.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Breast Mass Excision

PREOPERATIVE DIAGNOSIS: , Right breast mass with atypical proliferative cells on fine-needle aspiration.,POSTOPERATIVE DIAGNOSIS:,  Benign breast mass.,ANESTHESIA: , General,NAME OF OPERATION:,  Excision of right breast mass.,PROCEDURE:,  With the patient in the supine position, the right breast was prepped and draped in a sterile fashion.  A curvilinear incision was made directly over the mass in the upper-outer quadrant of the right breast.  Dissection was carried out around a firm mass, which was dissected with surrounding margins of breast tissue.  Hemostasis was obtained using electrocautery.  Frozen section exam showed a fibroadenoma with some proliferative hyperplasia within the fibroadenoma, but appeared benign.  The breast tissues were approximated using 4-0 Vicryl.  The skin was closed using 5-0 Vicryl running subcuticular stitches.  A sterile bandage was applied.  The patient tolerated the procedure well.,
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DESCRIPTION: Excision of right breast mass.  Right breast mass with atypical proliferative cells on fine-needle aspiration.

obstetrics / gynecology, atypical proliferative cells, fine needle aspiration, proliferative cells, breast mass, breast, needle, aspiration, fibroadenoma, excision, proliferative, mass,

The situation described involves a surgical procedure for the excision of a breast mass in the field of Obstetrics/Gynecology. Even though the postoperative diagnosis was benign, the presence of atypical proliferative cells preoperatively introduces a level of uncertainty and concern for both the patient and the medical team. Surgical excisions involving any proliferative breast condition carry some risk due to the potential for malignancy or future complications. However, given that the lesion was ultimately benign, the stakes are moderate rather than extremely high. The successful excision and benign diagnosis reduce the potential risk significantly.


Medical Specialty: Gastroenterology
Sample Name: Cecal Polyp Resection

PREOPERATIVE DIAGNOSIS:,  Cecal polyp.,POSTOPERATIVE DIAGNOSIS: , Cecal polyp.,PROCEDURE: , Laparoscopic resection of cecal polyp.,COMPLICATIONS: , None., ,ANESTHESIA:  ,General oral endotracheal intubation.,PROCEDURE:,  After adequate general anesthesia was administered the patient's abdomen was prepped and draped aseptically.  Local anesthetic was infiltrated into the right upper quadrant where a small incision was made.  Blunt dissection was carried down to the fascia which was grasped with Kocher clamps.  A bladed 11-mm port was inserted without difficulty.  Pneumoperitoneum was obtained using C02.  Under direct vision 2 additional, non-bladed, 11-mm trocars were placed, one in the left lower quadrant and one in the right lower quadrant.  There was some adhesion noted to the anterior midline which was taken down using the harmonic scalpel.  The cecum was visualized and found to have tattoo located almost opposite the ileocecal valve.  This was in what appeared to be an appropriate location for removal of this using the Endo GIA stapler without impinging on the ileocecal valve or the appendiceal orifice.  The appendix was somewhat retrocecal in position but otherwise looked normal.  The patient was also found to have ink marks in the peritoneal cavity diffusely indicating possible extravasation of dye.  There was enough however in the wall to identify the location of the polyp.  The lesion was grasped with a Babcock clamp and an Endo GIA stapler used to fire across this transversely. The specimen was then removed through the 12-mm port and examined on the back table.  The lateral margin was found to be closely involved with the specimen so I did not feel that it was clear.  I therefore lifted the lateral apex of the previous staple line and created a new staple line extending more laterally around the colon.  This new staple line was then opened on the back table and examined.  There was some residual polypoid material noted but the margins this time appeared to be clear.  The peritoneal cavity was then lavaged with antibiotic solution.  There were a few small areas of bleeding along the staple line which were treated with pinpoint electrocautery.  The trocars were removed under direct vision.  No bleeding was noted.  The bladed trocar site was closed using a figure-of-eight O Vicryl suture.  All skin incisions were closed with running 4-0 Monocryl subcuticular sutures.  Mastisol and Steri-Strips were placed followed by sterile Tegaderm dressing.  The patient tolerated the procedure well without any complications.
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DESCRIPTION: Laparoscopic resection of cecal polyp.  Local anesthetic was infiltrated into the right upper quadrant where a small incision was made.  Blunt dissection was carried down to the fascia which was grasped with Kocher clamps.

gastroenterology, polyp, laparoscopic resection, blunt dissection, kocher clamps, ileocecal valve, gia stapler, peritoneal cavity, cecal polyp, infiltrated, anesthetic

The procedure performed was a laparoscopic resection of a cecal polyp, which is a relatively routine surgical intervention in the field of gastroenterology, usually with a low risk of serious complications. There were no reported complications in this specific case, and the patient tolerated the procedure well. Therefore, while it's important for patient care, the stakes of this particular situation are not extremely high.


Medical Specialty: Obstetrics / Gynecology
Sample Name: External Cephalic Version

PREOPERATIVE DIAGNOSIS: , A 39-week intrauterine pregnancy with complete breech presentation.,POSTOPERATIVE DIAGNOSIS:,  A 39-week intrauterine pregnancy in vertex presentation, status post successful external cephalic version.,PROCEDURE: , External cephalic version.,COMPLICATIONS:,  None.,PROCEDURE IN DETAIL:  ,The patient was brought to Labor and Delivery where a reactive fetal heart tracing was obtained.  The patient was noted to have irregular contractions.  She was given 1 dose of subcutaneous terbutaline which resolved her contraction.  A bedside ultrasound was performed which revealed single intrauterine pregnancy and complete breech presentation.  There was noted to be adequate fluid.  Using manual pressure, the breech was manipulated in a forward roll fashion until a vertex presentation was obtained.  Fetal heart tones were checked intermittently during the procedure and were noted to be reassuring.  Following successful external cephalic version, the patient was placed on continuous external fetal monitoring.  She was noted to have a reassuring and reactive tracing for 1 hour following the external cephalic version.  She did not have regular contractions and therefore she was felt to be stable for discharge to home.  She was given appropriate labor instructions.
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DESCRIPTION: External cephalic version.  A 39-week intrauterine pregnancy with complete breech presentation.

obstetrics / gynecology, intrauterine pregnancy, vertex presentation, complete breech presentation, external cephalic version, fetal, contractions, pregnancy, breech, intrauterine,

An external cephalic version is a procedure performed to turn a fetus from a breech position to a head-down position (vertex presentation) before delivery. Although the procedure is common and usually safe, it involves maneuvering the fetus manually and has potential risks, such as fetal distress or placental abruption. In this scenario, the procedure was successful without complications, but given that it involves manipulating the fetus manually at full term (39 weeks), it is considered a high-stakes situation because of the potential risks involved to both the mother and fetus. The successful execution of the procedure without complications, however, reduces the stakes compared to if complications had occurred.


Medical Specialty: Surgery
Sample Name: Colonoscopy - 5

PROCEDURE: , Colonoscopy.,INDICATIONS: , Hematochezia, Personal history of colonic polyps.,MEDICATIONS:,  Midazolam 2 mg IV, Fentanyl 100 mcg IV,PROCEDURE:,  A History and Physical has been performed, and patient medication allergies have been reviewed.  The patient's tolerance of previous anesthesia has been reviewed.  The risks and benefits of the procedure and the sedation options and risks were discussed with the patient.  All questions were answered and informed consent was obtained.  Mental Status Examination:  alert and oriented.  Airway Examination:  normal oropharyngeal airway and neck mobility.  Respiratory Examination:  clear to auscultation.  CV Examination:  RRR, no murmurs, no S3 or S4.  ASA Grade Assessment:  P1 A normal healthy patient.  After reviewing the risks and benefits, the patient was deemed in satisfactory condition to undergo the procedure.  The anesthesia plan was to use conscious sedation.  Immediately prior to administration of medications, the patient was re-assessed for adequacy to receive sedatives.  The heart rate, respiratory rate, oxygen saturations, blood pressure, adequacy of pulmonary ventilation, and response to care were monitored throughout the procedure.  The physical status of the patient was re-assessed after the procedure.  After I obtained informed consent, the scope was passed under direct vision.  Throughout the procedure, the patient's blood pressure, pulse, and oxygen saturations were monitored continuously.  The colonoscope was introduced through the anus and advanced to the cecum, identified by appendiceal orifice & IC valve.  The quality of the prep was good.  The patient tolerated the procedure well.,FINDINGS:,1.  A sessile, non-bleeding polyp was found in the rectum.  The polyp was 5 mm in size.  Polypectomy was performed with a saline injection-lift technique using the snare.  Resection and retrieval were complete.  Estimated blood loss was minimal.,2.  One pedunculated, non-bleeding polyp was found in the sigmoid colon.  The polyp was 7 mm in size.  Polypectomy was performed with a hot forceps.  Resection and retrieval were complete.  Estimated blood loss was minimal.,3.  Multiple large-mouthed diverticula were found in the descending colon.,4.  Internal, non-bleeding, prolapsed with spontaneous reduction (grade II) hemorrhoids were found on retroflexion.,IMPRESSION:,1.  One 5 mm benign appearing polyp in the rectum.  Resected and retrieved.,2.  One 7 mm polyp in the sigmoid colon.  Resected and retrieved.,3.  Diverticulosis.,4.  Internal hemorrhoids were found.,RECOMMENDATION:,1.  High fiber diet.,2.  Await pathology results.,3.  Repeat colonoscopy for surveillance in 3 years.,4.  The findings and recommendations were discussed with the patient.,CPT CODE(S):,45385, Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by snare,technique.,45384, 59, Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by hot,biopsy forceps or bipolar cautery.,45381, 59, Colonoscopy, flexible, proximal to splenic flexure; with directed submucosal injection(s), any substance.,ICD9 CODE(S):,211.4, Benign neoplasm of rectum and anal canal.,211.3, Benign neoplasm of colon.,562.10, Diverticulosis of colon (without mention of hemorrhage).,455.2, Internal hemorrhoids with other complication,578.1, Blood in stool.,v12.72, Personal history of colonic polyps.
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DESCRIPTION: Colonoscopy due to hematochezia and personal history of colonic polyps.

The procedure described is a routine colonoscopy, which is generally a low-risk and commonly performed diagnostic and therapeutic procedure. The patient did not have any significant complications during the procedure and tolerated it well. Findings included benign-appearing polyps which were successfully resected with minimal blood loss. The ASA score indicates the patient is healthy. While there is always some risk associated with medical procedures involving sedation, the low ASA grade and successful management of the procedure suggest this is not a high-stakes situation. Additionally, there is no immediate life-threatening condition noted. However, pathology results are awaited to ascertain definitive diagnoses.


Medical Specialty: Neurology
Sample Name: Intracranial aneurysm - ER Visit

CHIEF COMPLAINT:,  Headache.,HPI: , This is a 24-year-old man who was seen here originally on the 13th with a headache and found to have a mass on CT scan.  He was discharged home with a follow up to neurosurgery on the 14th.  Apparently, an MRI the next day showed that the mass was an aneurysm and he is currently scheduled for an angiogram in preparation for surgery.  He has had headaches since the 13th and complains now of some worsening of his pain.  He denies photophobia, fever, vomiting, and weakness of the arms or legs.,PMH: , As above.,MEDS:,  Vicodin.,ALLERGIES:,  None.,PHYSICAL EXAM:  ,BP 180/110 Pulse 65 RR 18 Temp 97.5.,Mr. P is awake and alert, in no apparent distress.,HEENT:  Pupils equal, round, reactive to light, oropharynx moist, sclera clear.  ,Neck:  Supple, no meningismus.,Lungs:  Clear.,Heart:  Regular rate and rhythm, no murmur, gallop, or rub.  ,Abdomen:  Benign.,Neuro:  Awake and alert, motor strength normal, no numbness, normal gait, DTRs normal.  Cranial nerves normal.  ,COURSE IN THE ED:  ,Patient had a repeat head CT to look for an intracranial bleed that shows an unchanged mass, no blood, and no hydrocephalus.  I recommended an LP but he prefers not to have this done.  He received morphine for pain and his headache improved.  I've recommended admission but he has chosen to go home and come back in the morning for his scheduled angiogram.  He left the ED against my advice.  ,IMPRESSION: , Headache, improved.  Intracranial aneurysm.,PLAN: , The patient will return tomorrow am for his angiogram.
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DESCRIPTION: Headache, improved.  Intracranial aneurysm.

neurology, angiogram, mass, ct scan, intracranial aneurysm, headache, aneurysm, intracranial,

The patient has an intracranial aneurysm, a serious condition that can lead to life-threatening complications such as a hemorrhagic stroke if it ruptures. The fact that the patient chose to leave the emergency department against medical advice and with high blood pressure increases the risk. Although the patient's headache has improved with analgesics, his medical situation remains precarious until the scheduled angiogram and potential surgical intervention. These factors contribute to this being a high-stakes situation.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Chest Wall Tumor Resection

PREOPERATIVE DIAGNOSIS: , Left chest wall tumor, spindle cell histology.,POSTOPERATIVE DIAGNOSIS: , Left chest wall tumor, spindle cell histology with pathology pending.,PROCEDURE:  ,Resection of left chest wall tumor, partial resection of left diaphragm, left lower lobe lung wedge resection, left chest wall reconstruction with Gore-Tex mesh.,ANESTHESIA: , General endotracheal.,SPECIMEN:,  Left chest wall with tumor and left lower lobe lung wedge resection to pathology.,INDICATIONS FOR PROCEDURE:,  The patient is a 79-year-old male who began to experience back pain approximately 2 years ago, which increased.  Chest x-ray and CT scan revealed a 3 cm x 4 cm mass abutting the left chest wall inferior to the left scapula with pleural thickening.  A biopsy was performed at an outside hospital (Kaiser) and pathology was consistent with mesothelioma.  The patient had a metastatic workup, which was negative including a brain MRI and bone scan.  The bone scan showed only signal positivity in the left 9th rib near the tumor.  The patient has a significant past medical history consisting of coronary artery disease, hypertension, non-insulin dependent diabetes, longstanding atrial fibrillation, anemia, and hypercholesterolemia.  He and his family were apprised of the high-risk nature of this surgery preoperatively and informed consent was obtained.,PROCEDURE IN DETAIL: , The patient was brought to the operating room and placed in the supine position.  The patient was intubated with a double-lumen endotracheal tube.  Intravenous antibiotics were given.  A Foley catheter was placed.  The patient was placed in the right lateral decubitus position and the left chest was prepped and draped in the usual sterile fashion.  An incision approximately 8 inches long was made centered over the mass and extending slightly obliquely over the mass.  The skin and subcutaneous tissues were dissected sharply with the electrocautery.  Good hemostasis was obtained.  The tumor was easily palpable and clearly involving the 8th to 9th rib.  A thoracotomy was initially made above the mass in approximately the 7th intercostal space.  Inspection of the pleural cavity revealed multiple adhesions, which were taken down with a combination of blunt and sharp dissection.  The thoracotomy was extended anteriorly and posteriorly.  It was clear that in order to obtain an adequate resection of the tumor, approximately 4 rib segment of the chest wall would need to be resected.  The ribs of the chest wall were first cut at their anterior aspect.  The ribs 7, 8, 9, and 10 were serially transected after the interspaces were dissected with electrocautery.  Hemostasis was obtained with both electrocautery and clips.  The chest wall segment to be resected was retracted laterally and posteriorly.  It was clear that there were at least 2 areas where the tumor was invading the lung and a lengthy area of diaphragmatic involvement.  Inferiorly, the diaphragm was divided to provide a margin of at least 1 to 2 cm around the areas of tumor.  The spleen and the stomach were identified and were protected.  Inferiorly, the resection of the chest wall was continued in the 10th interspace.  The dissection was then carried posteriorly to the level of the spine.  The left lung at this point was further dissected out and multiple firings of the GIA 75 were used to perform a wedge resection of the left lower lobe, which provided a complete resection of all palpable and visible tumor in the lung.  A 2-0 silk tie was used to ligate the last remaining corner of lung parenchyma at the corner of the wedge resection.  Posteriorly, the chest wall segment was noted to have an area at the level of approximately T8 and T9, where the tumor involved the vertebral bodies.  The ribs were disarticulated, closed to or at their articulations with the spine.  Bleeding from the intercostal vessels was controlled with a combination of clips and electrocautery.  There was no disease grossly involving or encasing the aorta.,The posterior transection of the ribs was completed and the specimen was passed off of the field as a specimen to pathology for permanent section.  The specimen was oriented for the pathologist who came to the room.  Hemostasis was obtained.  The vent in the diaphragm was then closed primarily with a series of figure-of-8 #1 Ethibond sutures.  This produced a satisfactory diaphragmatic repair without undue tension.  A single 32-French chest tube was placed in the pleural cavity exiting the left hemithorax anteriorly.  This was secured with a #1 silk suture.  The Gore-Tex mesh was brought on to the field and was noted to be of adequate size to patch the resulting chest wall defect.  A series of #1 Prolene were placed in an interrupted horizontal mattress fashion circumferentially and tied down individually.  The resulting mesh closure was snug and deemed adequate.  The serratus muscle was reapproximated with figure-of-8 0 Vicryl.  The latissimus was reapproximated with a two #1 Vicryl placed in running fashion.  Of note, two #10 JP drains were placed over the mesh repair of the chest wall.  The subcutaneous tissues were closed with a running 3-0 Vicryl suture and the skin was closed with a 4-0 Monocryl.  The wounds were dressed.  The patient was brought from the operating room directly to the North ICU, intubated in stable condition.  All counts were correct.,
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DESCRIPTION: Resection of left chest wall tumor, partial resection of left diaphragm, left lower lobe lung wedge resection, left chest wall reconstruction with Gore-Tex mesh.

cardiovascular / pulmonary, chest wall tumor resection, diaphragm, left lower lobe, lung wedge resection, chest wall reconstruction, chest wall segment, gore tex mesh, chest wall tumor, chest wall, pleural cavity, lower lobe, wedge resection, resection, tumor, wall, chest, anesthesia, electrocautery, wedge, mesh, lung,

The case involves a complex surgical procedure for a 79-year-old patient with a history of several serious medical conditions, including coronary artery disease, hypertension, and atrial fibrillation. The surgery includes resection of a chest wall tumor which has implications on vital organs such as the lungs and diaphragm. The procedure itself is extensive, involving multiple organs and structures and has identified high-risk elements. Given the complexity of the surgery, the age of the patient, and the existing medical conditions, the stakes are high as both life and quality of life could be significantly impacted by the procedure and its outcomes.


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

Medical Specialty: Gastroenterology
Sample Name: Colonoscopy - 1

INDICATION: ,  Rectal bleeding, constipation, abnormal CT scan, rule out inflammatory bowel disease.,PREMEDICATION: ,See procedure nurse NCS form.,PROCEDURE:  ,
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DESCRIPTION: Colonoscopy due to rectal bleeding, constipation, abnormal CT scan, rule out inflammatory bowel disease.

gastroenterology, bleeding, ct scan, digital rectal exam, pentax video, rectal, cecal strap, cecum, colonic mucosa, colonoscope, colonoscopy, constipation, hemorrhoids, ileocecal valve, inflammatory bowel disease, lateral position, bowel disease, internal hemorrhoids, inflammatory

A colonoscopy is a medical procedure used to examine the inner lining of the large intestine for abnormalities such as inflammation, polyps, cancer, and other diseases. The indications for this procedure include rectal bleeding, constipation, and an abnormal CT scan, which could signal significant underlying issues like inflammatory bowel disease or cancer. While a colonoscopy is a routine procedure for a gastroenterologist, the stakes are high due to the potential for serious diagnoses and the need for patient care if a significant finding is made. However, the actual procedure itself is generally considered safe and routine for medical practitioners. The high stakes stem more from the implications of the diagnosis rather than the procedure's complexity or risk.


Medical Specialty: Radiology
Sample Name: Stress Test Bruce Protocol

PROTOCOL:,  Bruce.,PERTINENT MEDICATION: , None.,REASON FOR TEST:,  Chest pain.,PROCEDURE AND INTERPRETATION: ,1.  Baseline heart rate:  67.,2.  Baseline blood pressure:  150/86.,3.  Total time:  6 minute 51 seconds.,4.  METs:  10.1.,5.  Peak heart rate:  140.,6.  Percent of maximum-predicted heart rate:  90.,7.  Peak blood pressure:  200/92.,8.  Reason test terminated:  Shortness of breath and fatigue.,9.  Estimated aerobic capacity:  Average.,10. Heart rate response:  Normal.,11. Blood pressure response:  Hypertensive.,12. ST segment response:  Normal.,13. Chest pain:  None.,14. Symptoms:  None.,15. Arrhythmia:  None.,CONCLUSION:,1.  Average aerobic capacity.,2.  Normal heart rate and blood pressure response to exercise.,3.  No symptomatic electrocardiographic evidence of ischemia.,CONDITION: , Stable with normal vital signs.,DISPOSITION:  ,The patient was discharged home and was asymptomatic.,
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DESCRIPTION: Stress test with Bruce protocol due to chest pain.

The situation involves a stress test conducted on a patient experiencing chest pain, which can potentially indicate heart problems. Nonetheless, the test concluded without finding symptomatic evidence of ischemia, and the patient was discharged home asymptomatic. The stakes are moderate because while chest pain and hypertensive response warrant attention, the test results and overall condition appear stable.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Gardnerella Bacterial Vaginosis

CHIEF COMPLAINT: , Vaginal discharge with a foul odor.,HISTORY OF PRESENT ILLNESS: , This is a 25-year-old African-American female who states that for the past week she has been having thin vaginal discharge which she states is gray in coloration.  The patient states that she has also had frequency of urination.  The patient denies any burning with urination.  She states that she is sexually active and does not use condoms.  She does have three sexual partners.  The patient states that she has had multiple yeast infections in the past and is concerned that she may have one again.  The patient also states that she has had sexually transmitted diseases in her teens, but has not had one in many years.  The patient does state that she has never had HIV testing.  The patient states that she has not had any vaginal bleeding and does not have any abdominal pain.  The patient denies fevers or chills, nausea or vomiting, headaches or head trauma.  The patient also denies skin rashes or lesions.  She does state, however, there is one area of roughened skin on her right forearm that she is concerned it may be an infection of the skin.  The patient is G2 P2.  She has had some irregular Pap smears in the past.  Her last Pap smear was approximately 6 to 12 months ago.  The patient has had frequent urinary tract infections in the past.,PAST MEDICAL HISTORY:,1.  Bronchitis.,2.  Urinary tract infections.,3.  Vaginal candidiasis.,PAST SURGICAL HISTORY: , Cyst removal of the right breast.,SOCIAL HISTORY: , The patient does smoke approximately half a pack of cigarettes per day.  She denies alcohol or illicit drug use.,MEDICATIONS: , None.,ALLERGIES:,  No known medical allergies.,PHYSICAL EXAMINATION:,GENERAL:  This is an African-American female who appears her stated age of 25 years.  She is well nourished, well developed, and in no acute distress.  The patient is pleasant.,VITAL SIGNS:  Afebrile.  Blood pressure is mildly over 96/68, pulse is 68, respiratory rate 12, and pulse oximetry of 98% on room air.,HEART:  Regular rate and rhythm.  Clear S1 and S2.  No murmur, rub or gallop is appreciated.,LUNGS:  Clear to auscultation bilaterally.  No wheezes, rales or rhonchi.,ABDOMEN:  Soft, nontender, nondistended.  Positive bowel sounds throughout.,SKIN:  Warm, dry and intact.  No rash or lesion.,PSYCH:  Alert and oriented to person, place, and time.,NEUROLOGIC:  Cranial nerves II through XII are intact bilaterally.  No focal deficits are appreciated.,GENITOURINARY:  The pelvic exam done shows external genitalia without abnormalities or lesions.  There is a white-to-yellow discharge.  Transformation zone is identified.  The cervix is mildly friable.  Vaginal vault is without lesions.  There is no adnexal tenderness.  No adnexal masses.  No cervical motion tenderness.  Cervical swabs and vaginal cultures are obtained.,DIAGNOSTIC STUDIES: , Urinalysis shows 3+ bacteria, however, there are no wbc's.  No squamous epithelial cells and no other signs of infection.  There is no glucose.  The patient's cervical swabs and cultures are obtained and there are positive clue cells.  Negative Trichomonas.  Negative fungal elements and Chlamydia and gonorrhea are pending at this time.  Urinalysis is sent for culture and sensitivity.,ASSESSMENT:,: Gardnerella bacterial vaginosis.,PLAN: , The patient will be treated with metronidazole 500 mg p.o. twice a day x7 days.  The patient will follow up with her primary care provider.,
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DESCRIPTION: Vaginal discharge with a foul odor.

Vaginal discharge with a foul odor.

The case involves a common infection, Gardnerella bacterial vaginosis, which is typically not life-threatening and is treatable with antibiotics. The patient does not present with symptoms indicating a severe or complicated infection (e.g., fever, abdominal pain). While there are elements of her medical and sexual history that require attention (like multiple partners and irregular Pap smears), they do not elevate this encounter to a high-stakes scenario, particularly since there is a clear treatment plan in place and no immediate danger to the patient's life or health.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: PAF - 6-Month Followup

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

cardiovascular / pulmonary, atrial fibrillation, ekg, paroxysmal atrial fibrillation, chest pains, pedal edema, hyperthyroidism, paf, atrial,

The situation involves a follow-up medical appointment for a patient with paroxysmal atrial fibrillation, as well as other conditions like hyperthyroidism, dyslipidemia, and mild chest pain. While the patient's symptoms and the presence of chest pain could potentially indicate serious issues, the healthcare provider's impression and plan suggest that these are manageable under medical supervision. The patient's condition doesn't appear immediately life-threatening, but it involves multiple risk factors which are being actively monitored and managed, hence a moderate level of stakes. Furthermore, the patient is instructed to return for a stress echo to rule out more serious causes of chest pain, adding some urgency to the situation.


Medical Specialty: Urology
Sample Name: Inguinal Hernia Repair - 1

PREOPERATIVE DIAGNOSIS:,  Right inguinal hernia.,POSTOPERATIVE DIAGNOSIS:,  Right inguinal hernia.,PROCEDURE:,  Right inguinal hernia repair.,INDICATIONS FOR PROCEDURE: , This patient is a 9-year-old boy with a history of intermittent swelling of the right inguinal area consistent with a right inguinal hernia.  The patient is being taken to the operating room for inguinal hernia repair.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room, placed supine, put under general endotracheal anesthesia.  The patient's inguinal and scrotal area were prepped and draped in the usual sterile fashion.  An incision was made in the right inguinal skin crease.  The incision was taken down to the level of the aponeurosis of the external oblique, which was incised up to the level of the external ring.  The hernia sac was verified and dissected at the level of the internal ring and a high ligation performed.  The distal remnant was taken to its end and excised.  The testicle and cord structures were placed back in their native positions.  The aponeurosis of the external oblique was reapproximated with 3-0 Vicryl as well as the Scarpa's, the skin closed with 5-0 Monocryl and dressed with Steri-Strips.  The patient was extubated in the operating room and taken back to the recovery room.  The patient tolerated the procedure well.
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DESCRIPTION: A 9-year-old boy with a history of intermittent swelling of the right inguinal area consistent with a right inguinal hernia, taken to the operating room for inguinal hernia repair.

urology, inguinal skin crease, inguinal hernia repair, external oblique, hernia repair, inguinal hernia, inguinal, hernia,

The situation describes a surgical procedure for an inguinal hernia repair in a young child. While any surgical procedure comes with inherent risks and requires precise execution, inguinal hernia repairs are common and typically considered low-risk surgeries when performed by experienced professionals in a controlled environment. The description suggests that the procedure was conducted without complications, which further reduces the stakes. However, given the age of the patient and the necessity of general anesthesia, there is still a moderate level of risk involved.


Medical Specialty: General Medicine
Sample Name: Gen Med Progress Note - 11

SUBJECTIVE:,  The patient is a 66-year-old female who presents to the clinic today for a five-month recheck on her type II diabetes mellitus, as well as hypertension.  While here she had a couple of other issues as well.  She stated that she has been having some right shoulder pain.  She denies any injury but certain range of motion does cause it to hurt.  No weakness, numbness or tingling.  As far as her diabetes she states that she only checks her blood sugars in the morning and those have all been ranging less than 100.  She has not been checking any two hours after meals.  Her blood pressures when she does check them have been running normal as well but she does not have any record of these present with her.  No other issues or concerns.  Upon review of her chart it did show that she had a benign breast biopsy done back on 06/11/04 and was told to have a repeat mammogram in six months but she has never had that done so she is needing to have this done as well.,ALLERGIES: , None.,MEDICATIONS:,  She is on Hyzaar 50/12.5 one-half p.o. daily, coated aspirin daily, lovastatin 40 mg one-half tab p.o. daily, multivitamin daily, metformin 500 mg one tab p.o. b.i.d.; however, she has been skipping her second dose during the day.,SOCIAL HISTORY:,  She is a nonsmoker.,REVIEW OF SYSTEMS:,  As noted above.,OBJECTIVE:,Vital Signs:  Temperature:  98.2.  Pulse:  64.  Respirations:  16.  Blood pressure:  110/56.  Weight:  169.,General:  Alert and oriented x 3.  No acute distress noted.,Neck:  No lymphadenopathy, thyromegaly, JVD or bruits.,Lungs:  Clear to auscultation.,Heart:  Regular rate and rhythm without murmur or gallops present.,Breasts:  Exam performed with a female nurse present.  The breasts do have some scars present underneath them bilaterally from prior breast reduction surgery.  There is no axillary adenopathy or tenderness.  Breasts appear to be symmetric.  There was no nipple discharge or retraction.  No breast tissue retraction noted in either the sitting or the supine position.  Upon palpation there were no palpable lumps or bumps and no palpable discharge.,Musculoskeletal:  She did have full range of motion of her shoulders.  She did have tenderness upon palpation over the right bicipital tendon.  There is no swelling, crepitus or discoloration noted.,MEDICAL DECISION MAKING:  Most recent hemoglobin A1c was 5.6% back in October 2004.  Most recent lipid checks were obtained back in July 2004.  We have not had this checked since that time.,ASSESSMENT:,1.  Type II diabetes mellitus.,2.  Hypertension.,3.  Right shoulder pain.,4.  Hyperlipidemia.,PLAN:,1.  She is going to go to lab to obtain a hemoglobin A1c, BMP, lipids, CPK, liver enzymes and quantitative microalbumin.,2.  We are going to set her up for a diagnostic bilateral mammogram due to a history of abnormal mammogram in the past which subsequently showed a benign breast cyst.,3.  I told her for her shoulder to take ibuprofen 600 mg three times daily with her meals for a minimum of the next one week.,4.  She is going to follow up in the clinic in three months for a complete comprehensive examination.  If any questions, concerns or problems arise between now and then she should let us know.
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DESCRIPTION: 5-month recheck on type II diabetes mellitus, as well as hypertension.

The patient's situation involves management of chronic conditions such as type II diabetes mellitus and hypertension, as well as addressing new issues like right shoulder pain and a follow-up on a past benign breast biopsy. While managing diabetes and hypertension are important, the patient seems to be currently stable with good blood sugar readings and normal blood pressure. The right shoulder pain, though uncomfortable, doesn't appear severe and is being managed conservatively. Moreover, while not having the past recommended mammogram could raise concern, it's not immediately life-threatening. Overall, while the medical issues require attention and follow-up, they do not pose an immediate high risk to the patient's health.


Medical Specialty: Surgery
Sample Name: Low-Transverse C-Section - 6

PREOPERATIVE DIAGNOSES:,1.  Pregnancy at 40 weeks.,2.  Failure to progress.,3.  Premature prolonged rupture of membranes.,4.  Group B strep colonization.,POSTOPERATIVE DIAGNOSIS:,1.  Pregnancy at 40 weeks.,2.  Failure to progress.,3.  Premature prolonged rupture of membranes.,4.  Group B strep colonization.,5.  Delivery of viable male neonate.,PROCEDURE PERFORMED: , Primary low transverse cesarean section via Pfannenstiel incision.,ANESTHESIA:  ,Spinal.,ESTIMATED BLOOD LOSS: , 1000 cc.,FLUID REPLACEMENT: , 2700 cc crystalloid.,URINE:,  500 cc clear yellow urine in the Foley catheter.,INTRAOPERATIVE FINDINGS:  ,Normal appearing uterus, tubes, and ovaries.  A viable male neonate with Apgars of 9 and 9 at 1 and 5 minutes respectively.  Infant weight equaled to 4140 gm with clear amniotic fluid.  The umbilical cord was wrapped around the leg tightly x1.  Infant was in a vertex, right occiput anterior position.,INDICATIONS FOR PROCEDURE:  ,The patient is a 19-year-old G1 P0 at 41 and 1/7th weeks' intrauterine pregnancy.  She presented at mid night on 08/22/03 complaining of spontaneous rupture of membranes, which was confirmed in Labor and Delivery.  The patient had a positive group beta strep colonization culture and was started on penicillin.  The patient was also started on Pitocin protocol at that time.  The patient was monitored throughout the morning showing some irregular contractions every 5 to 6 minutes and then eventually no contractions on the monitor.  IUPC was placed without difficulty and contractions appeared to be regular, however, they were inadequate amount of the daily units.  The patient was given a rest from the Pitocin.  She walked and had a short shower.  The patient was then placed back on Pitocin with IUPC in place and we were unable to achieve adequate contractions.  Maximum cervical dilation was 5 cm, 80% effaced, negative 2 station, and cephalic position.  At the time of C-section, the patient had been ruptured for over 24 hours and it was determined that she would not progress in her cervical dilation, as there was suspected macrosomia on ultrasound.  Options were discussed with the patient and family and it was determined that we will take her for C-section today.  Consent was signed.  All questions were answered with Dr. X present.,PROCEDURE: , The patient was taken to the operative suite where a spinal anesthetic was placed.  She was placed in the dorsal supine position with left upward tilt.  She was prepped and draped in the normal sterile fashion and her spinal anesthetic was found to adequate.  A Pfannenstiel incision was made with a first scalpel and carried through the underlying layer of fascia with a second scalpel.  The fascia was incised in the midline and extended laterally using curved Mayo scissors.  The superior aspect of the fascial incision was grasped with Ochsner and Kocher clamps and elevated off the rectus muscles.  Attention was then turned to the inferior aspect of the incision where Kocher clamps were used to elevate the fascia off the underlying rectus muscle.  The rectus muscle was separated in the midline bluntly.  The underlying peritoneum was tented up with Allis clamps and incised using Metzenbaum scissors.  The peritoneum was then bluntly stretched.  The bladder blade was placed.  The vesicouterine peritoneum was identified, tented up with Allis' and entered sharply with Metzenbaum scissors.  The incision was extended laterally and the bladder flap created digitally.  The bladder blade was then reinserted in the lower uterine segment.  A low transverse uterine incision was made with a second scalpel.  The uterine incision was extended laterally bluntly.  The bladder blade was removed and the infant's head was delivered with the assistance of a vacuum.  Infant's nose and mouth were bulb suctioned and the body was delivered atraumatically.  There was, of note, an umbilical cord around the leg tightly x1.,Cord was clamped and cut.  Infant was handed to the waiting pediatrician.  Cord gas was sent for pH as well as blood typing.  The placenta was manually removed and the uterus was exteriorized and cleared of all clots and debris.  The uterine incision was grasped circumferentially with Alfred clamps and closed with #0-Chromic in a running locked fashion.  A second layer of imbricating stitch was performed using #0-Chromic suture to obtain excellent hemostasis.  The uterus was returned to the abdomen.  The gutters were cleared of all clots and debris.  The rectus muscle was loosely approximated with #0-Vicryl suture in a single interrupted fashion.  The fascia was reapproximated with #0-Vicryl suture in a running fashion.  The subcutaneous Scarpa's fascia was then closed with #2-0 plain gut.  The skin was then closed with staples.  The incision was dressed with sterile dressing and bandage.  Blood clots were evacuated from the vagina.  The patient tolerated the procedure well.  The sponge, lap, and needle counts were correct x2.  The mother was taken to the recovery room in stable and satisfactory condition.
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DESCRIPTION: Primary low transverse cesarean section via Pfannenstiel incision.  Pregnancy at 40 weeks, failure to progress, premature prolonged rupture of membranes, group B strep colonization, and delivery of viable male neonate.

surgery, c-section, cesarean section, low transverse, pregnancy, rupture of membranes, cervical dilation, kocher clamps, metzenbaum scissors, vicryl suture, pfannenstiel incision, uterine incision, rectus muscles, incision, transverse, colonization, rectus, muscles, bladder, uterine, section, fascia,

In this scenario, a 19-year-old patient at 41 weeks of pregnancy underwent a cesarean section due to failure to progress and other factors like prolonged rupture of membranes and Group B strep colonization. Though C-sections are common, any surgical procedure, especially involving childbirth, can be high-stakes because of the potential risks to both the mother and the newborn. The stakes are heightened by the complications like uterine rupture, infection, or excessive blood loss. However, since there was successful delivery of a healthy neonate, with proper monitoring and a capable surgical team, the risks could be mitigated effectively.


Medical Specialty: Neurosurgery
Sample Name: Ventriculostomy

PREOPERATIVE DIAGNOSIS: , Aqueductal stenosis.,POSTOPERATIVE DIAGNOSIS:,  Aqueductal stenosis.,TITLE OF PROCEDURE:  ,Endoscopic third ventriculostomy.,ANESTHESIA: , General endotracheal tube anesthesia.,DEVICES:,  Bactiseal ventricular catheter with an Aesculap burr hole port.,SKIN PREPARATION:  ,ChloraPrep.,COMPLICATIONS: , None.,SPECIMENS: , CSF for routine studies.,INDICATIONS FOR OPERATION:  ,Triventricular hydrocephalus most consistent with aqueductal stenosis.  The patient having a long history of some intermittent headaches, macrocephaly.,OPERATIVE PROCEDURE: , After satisfactory general endotracheal tube anesthesia was administered, the patient was positioned on the operating table in supine position with the head neutral.  The right frontal area was shaven and then the head was prepped and draped in a standard routine manner.  The area of the proposed scalp incision was infiltrated with 0.25% Marcaine with 1:200,000 epinephrine.  A curvilinear scalp incision was made extending from just posterior to bregma curving up in the midline and then going off to the right anterior to the coronal suture.  Two Weitlaner were used to hold the scalp open.  A burr hole was made just anterior to the coronal suture and then the dura was opened in a cruciate manner and the pia was coagulated.  Neuropen was introduced directly through the parenchyma into the ventricular system, which was quite large and dilated.  CSF was collected for routine studies.  We saw the total absence of __________  consistent with the congenital form of aqueductal stenosis and a markedly thinned down floor of the third ventricle.  I could bend the ventricular catheter and look back and see the aqueduct, which was quite stenotic with a little bit of chorioplexus near its opening.  The NeuroPEN was then introduced through the midline of the floor of the third ventricle anterior to the mamillary bodies in front of the basilar artery and then was gently enlarged using NeuroPEN __________  various motions.  We went through the membrane of Liliequist.  We could see the basilar artery and the clivus, and there was no significant bleeding from the edges.  The Bactiseal catheter was then left to 7 cm of length because of her macrocephaly and secured to a burr hole port with a 2-0 Ethibond suture.  The wound was irrigated out with bacitracin and closed using 3-0 Vicryl for the deep layer and a Monocryl suture for the scalp followed by Mastisol and Steri-Strips.  The patient tolerated the procedure well.
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DESCRIPTION: Endoscopic third ventriculostomy.

Endoscopic third ventriculostomy.

neurosurgery, aqueductal stenosis, ventriculostomy, triventricular hydrocephalus, neuropen, endoscopic third ventriculostomy, endotracheal tube anesthesia, burr hole port, aqueductal,

The situation involves a neurosurgical procedure, specifically an endoscopic third ventriculostomy, which is performed to treat aqueductal stenosis leading to hydrocephalus. Neurosurgery typically involves high-stakes scenarios due to the complexity of the procedures and the critical nature of the brain structures involved. The procedure requires precision and carries significant risks, including potential postoperative complications. Although there were no complications noted in this case, the inherent risks associated with any brain surgery make it a high-stakes situation.


Medical Specialty: Surgery
Sample Name: Axillary Dissection & Mass Excision

PREOPERATIVE DIAGNOSIS:,  Bilateral axillary masses, rule out recurrent Hodgkin's disease.,POSTOPERATIVE DIAGNOSIS:  ,Bilateral axillary masses, rule out recurrent Hodgkin's disease.,PROCEDURE PERFORMED:,1.  Left axillary dissection with incision and drainage of left axillary mass.,2.  Right axillary mass excision and incision and drainage.,ANESTHESIA: , LMA.,SPECIMENS:,  Left axillary mass with nodes and right axillary mass.,ESTIMATED BLOOD LOSS:  ,Less than 30 cc.,INDICATION: , This 56-year-old male presents to surgical office with history of bilateral axillary masses.  Upon evaluation, it was noted that the patient has draining bilateral masses with the left mass being approximately 8 cm in diameter upon palpation and the right being approximately 4 cm in diameter.  The patient had been continued on antibiotics preoperatively.  The patient with history of Hodgkin's lymphoma approximately 18 years ago and underwent therapy at that time and he was declared free of disease since that time.  Consent for possible recurrence of Hodgkin's lymphoma warranted exploration and excision of these masses.  The patient was explained the risks and benefits of the procedure and informed consent was obtained.,GROSS FINDINGS: , Upon dissection of the left axillary mass, the mass was removed in toto and noted to have a cavity within it consistent with an abscess.,No loose structures were identified and sent for frozen section, which upon intraoperative consultation with Pathology Department revealed no obvious evidence of lymphoma, however, the confirmed pathology report is pending at this time.  The right axillary mass was excised without difficulty without requiring full axillary dissection.,PROCEDURE: , The patient was placed in supine position after appropriate anesthesia was obtained and a sterile prep and drape complete.  A #10 blade scalpel was used to make an elliptical incision about the mass itself extending this incision further to aid in the mobilization of the mass.  Sharp dissection was utilized with Metzenbaum scissors about the mass to maintain the injury to the skin structure and upon showing out the mass, Bovie electrocautery was utilized adjacent to the wall structure to maintain hemostasis.  Identification of the axillary anatomy was made and care was made to avoid injury to nerve, vessel or musculature.  Once this mass was removed in toto, lymph node structures were as well delivered with this mass and sent to frozen section as well the specimen was sent to gram stain and culture.  Upon revaluation of the incisional site, it was noted to be hemostatic.  Warm lap sponge was then left in place at this site.  Next, attention was turned to the right axilla where a #10 blade scalpel was used to make a 4 cm incision about the mass including the cutaneous structures involved with the erythematous reaction.  This was as well removed in toto and sent to Pathology for gram stain and culture as well as pathologic evaluation.  This site was then made hemostatic as well with the aid of Bovie electrocautery and approximation of the deep dermal tissues after irrigation with warm saline was then done with #3-0 Vicryl suture followed by #4-0 Vicryl running subcuticular stitch.  Steri-Strips were applied.  Attention was returned back left axilla, which upon re-exploration was noted to be hemostatic and a #7 mm JP was then introduced making a skin stab inferior to the incision and bringing the end of the drain through this incision.  This was placed within the incision site, ________ drainage of the axillary potential space.  Approximation of the deep dermal tissues were then done with #3-0 Vicryl in an interrupted technique followed by #4-0 Vicryl with running subcuticular technique.  Steri-Strips and sterile dressings were applied.  JP bulb was then placed to suction and sterile dressings were applied to both axilla.  The patient tolerated the procedure well and sent to postanesthesia care unit in a stable condition.  He will be discharged to home upon ability of the patient to have pain tolerance with Vicodin 1-2 as needed every six hours for pain and continue on Keflex antibiotics until gram stain culture proves otherwise.
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DESCRIPTION: Left axillary dissection with incision and drainage of left axillary mass.  Right axillary mass excision and incision and drainage.   Bilateral axillary masses, rule out recurrent Hodgkin's disease.

surgery, incision and drainage, axillary mass excision, axillary dissection, hodgkin's disease, axillary mass, mass, incision, axillary,

The situation involves a surgical procedure on a 56-year-old male patient with a history of Hodgkin's lymphoma, who presents with bilateral axillary masses. The primary concern is to rule out the recurrence of Hodgkin's disease, a serious cancer. The stakes are high due to the potential implication of a cancer diagnosis, the risks involved in surgical procedures, and the patient's prior cancer history. Successful management of the surgery and accurate diagnosis are critical for the patient's health outcomes.


Medical Specialty: Letters
Sample Name: Ophthalmology - Letter - 1

XYZ, O.D.,RE:  ABC,DOB:  MM/DD/YYYY,Dear Dr. XYZ:,Thank you for your referral of patient ABC.  The patient was referred for evaluation of cataracts bilaterally.,On examination, the patient was seeing 20/40 in her right eye and 20/50 in the left eye.  Extraocular muscles were intact, visual fields were full to confrontation OU, and applanations are 12 mmHg bilaterally.  There is no relative afferent pupillary defect.  On slit lamp examination, lids and lashes were within normal limits.  The conj is quiet.  The cornea shows 1+ guttata bilaterally.  The AC is deep and quiet and irises are within normal limits bilaterally.  There is a dense 3 to 4+ nuclear sclerotic cataract in each eye.  On dilated fundus examination, cup-to-disc ratio is 0.1 OU.  The vitreous, macula, vessels, and periphery all appear within normal limits.,Impression:  It appears that Ms. ABC' visual decline is caused by bilateral cataracts.  She would benefit from having removed.  The patient also showed some mild guttata OU indicating possible early Fuchs dystrophy.  The patient should do well with cataract surgery and I have recommended this and she agreed to proceed with the first eye here shortly.  I will keep you up to date of her progress and any new findings as we perform her surgery in each eye.,Again, thank you for your kind referral of this kind lady and I will be in touch with you.,Sincerely,,
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DESCRIPTION: The patient was referred for evaluation of cataracts bilaterally

letters, extraocular, applanations, slit lamp, visual field, ophthalmology, visual, guttata, surgery, cataracts, eye,

The situation involves a routine ophthalmology assessment concerning cataracts, a common eye condition, and the potential presence of mild guttata indicating early Fuchs dystrophy. The recommendation for cataract surgery is standard and relatively low-risk, with the prognosis expected to be good. Although the procedure is important for the patient's vision improvement, it is not an emergency or life-threatening situation.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Non-Q-wave Myocardial Infarction

REASON FOR CONSULT: , A patient with non-Q-wave myocardial infarction.,HISTORY OF PRESENT ILLNESS: , The patient is a pleasant 52-year-old gentleman with a history of diabetes mellitus, hypertension, and renal failure, on dialysis, who presented with emesis, dizziness, and nausea for the last few weeks.  The patient reports having worsening emesis and emesis a few times.  No definite chest pains.  The patient is breathing okay.  The patient denies orthopnea or PND.,PAST MEDICAL HISTORY:,1.  Diabetes mellitus.,2.  Hypertension.,3.  Renal failure, on dialysis.,MEDICATIONS:,  Aspirin, Coreg, doxazosin, insulin, metoclopramide, simvastatin, and Starlix.,ALLERGIES:  ,NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY: , The patient denies tobacco, alcohol or drug use.,FAMILY HISTORY: , Negative for early atherosclerotic heart disease.,REVIEW OF SYSTEMS: , General:  The patient denies fever or chills.  Pulmonary:  The patient denies hemoptysis.  Cardiovascular:  Refer to HPI.  GI:  The patient denies hematemesis or melena.  The rest of systems review is negative.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Pulse 71, blood pressure 120/70, and respiratory rate 18.,GENERAL:  A well-nourished, well-developed male in no acute distress.,HEENT:  Normocephalic, atraumatic.  Pupils seem to be equal, round, and reactive.  Extraocular muscles are full, but the patient has left eye ptosis.,NECK:  Supple without JVD or lymphadenopathy.,LUNGS:  Clear to auscultation bilaterally.,CARDIOVASCULAR:  PMI is displaced 0.5 cm lateral to the midclavicular line.  Regular rate and rhythm, S1, S2.  No definite S3, 2/6 holosystolic murmur at the apex radiating to the axilla.,ABDOMEN:  Positive bowel sounds, nondistended and nontender.  No hepatosplenomegaly.,EXTREMITIES:  Trace pedal edema.,EKG shows atrial fibrillation with rapid ventricular response at 164 with old anteroseptal myocardial infarction and old inferior wall myocardial infarction.  Subsequent EKG in sinus rhythm shows sinus rhythm with old inferior wall myocardial infarction and probable anteroseptal myocardial infarction with Q-waves in V1, V2, and up to V3.,LABORATORY EXAM: , WBC 28,800, hemoglobin 13.6, hematocrit 40, and platelets 266,000.  PT 11.3, INR 1.1, and PTT 24.1.  Sodium 126, potassium 4.3, chloride 86, CO2 26, glucose 371, BUN 80, and creatinine 8.4.  CK was 261, then 315, and then 529 with CK-MB of 8.06, then 8.69, and then 24.6.  Troponin was 0.051, then 0.46, and then 19.8 this morning.,IMPRESSION:,1.  Paroxysmal atrial fibrillation.  The heart rate was slowed down with IV Cardizem, the patient converted to sinus rhythm.  The patient is currently in sinus rhythm.,2.  Emesis.  The etiology is unclear.  The patient reports that the emesis is better.  The patient is just having some nausea.,3.  Non-Q-wave myocardial infarction.  EKG shows atrial fibrillation with old anteroseptal myocardial infarction and old inferior wall myocardial infarction.,4.  Diabetes mellitus.,5.  Renal failure.,6.  Hypertension.,7.  Hypercholesterolemia.,PLAN:,1.  We will start amiodarone to keep from going back into atrial fibrillation.,2.  Echocardiogram.,3.  Aspirin and IV heparin.,4.  Serial CK-MB and troponin.,5.  Cardiac catheterization, possible percutaneous coronary intervention.  The risks, benefits, and alternatives were explained to the patient through a translator.  The patient understands and wishes to proceed.,6.  IV Integrilin.
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DESCRIPTION: A patient with non-Q-wave myocardial infarction.  No definite chest pains.  The patient is breathing okay.  The patient denies orthopnea or PND.

The patient presents with a non-Q-wave myocardial infarction along with a history of diabetes, hypertension, and renal failure which cumulatively increase the risk of serious complications. The situation involves significant medical interventions such as starting amiodarone, performing an echocardiogram, administering aspirin and IV heparin, monitoring cardiac enzymes, and potentially conducting a cardiac catheterization with percutaneous coronary intervention. While the patient is currently stable with no acute distress, the combination of a heart condition, past medical history, and ongoing treatment elevates the situation to high-stakes due to the potential for life-threatening complications.