Medical Specialty: Consult - History and Phy.
Sample Name: Adjustment Disorder & Encopresis

REASON FOR REFERRAL:,  The patient was referred to me by Dr. X of the Clinic due to concerns regarding behavioral acting out as well as encopresis.  This is a 90-minute initial intake completed on 10/03/2007.  I met with the patient's mother individually for the entire session.  I reviewed with her the treatment, consent form, as well as the boundaries of confidentiality, and she stated that she understood these concepts.,PRESENTING PROBLEMS: , Mother reported that her primary concern in regard to the patient had to do with his oppositionality.  She was more ambivalent regarding addressing the encopresis.  In regards to his oppositionality, she reported that the onset of his oppositionality was approximately at 4 years of age, that before that he had been a very compliant and happy child, and that he has slowly worsened over time.  She noted that the oppositionality occurred approximately after his brother, who has multiple medical problems, was born.  At that time, mother had spent 2 months back East with the brother due to his feeding issues and will have to go again next year.  She reported that in terms of the behaviors that he loses his temper frequently, he argues with her that he defies her authority that she has to ask him many times to do things, that she has to repeat instructions, that he ignores her, that he whines, and this is when he is told to do something that he does not want to do.  She reported that he deliberately annoys other people, that he can be angry and resentful.  She reported that he does not display these behaviors with the father nor does he display them at home, but they are specific to her.  She reported that her response to him typically is that she repeats what she wants him to do many, many times, that eventually she gets upset.  She yells at him, talks with him, and tries to make him go and do what she wants him to do.  Mother also noted that she probably ignores some his misbehaviors.  She stated that the father tends to be more firm and more direct with him, and that, the father sometimes thinks that the mother is too easy on him.  In regards to symptoms of depression, she denied symptoms of depression, noting that he tends to only become unhappy when he has to do something that he does not want to do, such as go to school or follow through on a command.  She denied any suicidal ideation.  She denied all symptoms of anxiety.  PTSD was denied.  ADHD symptoms were denied, as were all other symptoms of psychopathology.,In regards to the encopresis, she reported that he has always soiled, he does so 2 to 3 times a day.  She reported that he is concerned about this issue.  He currently wears underwear and had a pull-up.  She reported that he was seen at the Gastroenterology Department here several years ago, and has more recently been seen at the Diseases Center, seen by Dr. Y, reported that the last visit was several months ago, that he is on MiraLax.  He does sit on the toilet may be 2 times a day, although that is not consistent.  Mother believes that he is probably constipated or impacted again.  He refuses to eat any fiber.  In regards to what happens when he soils, mother basically takes full responsibility.  She cleans and changes his underwear, thinks of things that she has tried, she mostly gets frustrated, makes negative comments, even though she knows that he really cannot help it.  She has never provided him with any sort of rewards, because she feels that this is something he just needs to learn to do.  In regards to other issues, she noted that he becomes frustrated quite easily, especially around homework, that when mother has to correct him, or when he has had difficulty doing something that he becomes upset, that he will cry, and he will get angry.  Mother's response to him is that either she gets agitated and raises her voice, tells him to stop etc.  Mother reported it is not only with homework, but also with other tasks, such as if he is trying to build with his LEGOs and things do not go well.,DEVELOPMENTAL BACKGROUND: , The patient was reported to be the 8 pound 12 ounce product of a planned and noncomplicated pregnancy and emergency cesarean delivery.  The patient presented in a breech position.  Mother denied the use of drugs, alcohol, or tobacco during the pregnancy.  No sleeping or eating issues were present in the perinatal period.  Temperament was described as easy.  He was described as a cuddly baby.  No concerns expressed regarding his developmental milestones.  No serious injuries reported.  No hospitalizations or surgeries.  No allergies.  The patient has been encopretic for all of his life.  He currently is taking MiraLax.,FAMILY BACKGROUND: , The patient lives with his mother who is age 37, and is primarily a homemaker, but does work approximately 48 hours a month as a beautician; with his father, age 35, who is a police officer; and also, with his younger brother who is age 3, and has significant medical problems as will be noted in a moment.  Mother and father have been together since 1997, married in 1999.  The maternal grandmother and grandfather are living and are together, and live in the Central California Coast Area.  There is one maternal aunt, age 33, and then, two adopted maternal aunt and uncle, age 18 and age 13.  In regards to the father's side of the family, the paternal grandparents are divorced.  Grandfather was in Arkansas, grandmother lives in Dos Palos.  The patient does not see his grandfather.  Mother stated that her relationship with her child was as described, that he very much stresses her out, that she wishes that he was not so defiant, that she finds him to be a very stressful child to deal with.  In regards to the relationship with the father, it was reported that the father tends to leave most of the parenting over to the mother, unless she specifically asks him to do something, and then, he will follow through and do it.  He will step in and back mother up in terms of parenting, tell the child not to speak to his mother that way etc.  Mother reported that he does spend some time with the children, but not as much as mother would like him to, but occasionally, he will go outside and do things with them.  The mother reported that sometimes she has a problem in interfering with his parenting, that she steps in and defends The patient.  It was reported that mother stated that she tries the parenting technique, primarily of yelling and tried time-out, although her description suggests that she is not doing time-out correctly, as he simply gets up from his time-out, and she does not follow through.  Mother reported that she and the patient are very much alike in temperament, and this has made things more difficult.  Mother tends to be stubborn and gets angry easily also.  Mother reported becoming fatigued in her parenting, that she lets him get away with things sometimes because she does not want to punish him all day long, sometimes ignores problems that she probably should not ignore.  There was reported to be jealousy between The patient and his brother, B.  B evidently has some heart problems and feeding issues, and because of that, tends to get more attention in terms of his medical needs, and that the patient is very jealous of that attention and feels that B is favored and that he get things that The patient does not get, and that there is some tension between the brothers.  They do play well together; however, The patient does tend to be somewhat intrusive, gets in his space, and then, B will hit him.  Mother reported that she graduated from high school, went to Community College, and was an average student.  No learning problems.  Mother has a history of depression.  She has currently been taking 100 mg of Zoloft administered by her primary medical doctor.  She is not receiving counseling.  She has been on the medications for the last 5 years.  Her dosage has not been changed in a year.  She feels that she is getting more irritable and more angry.  I  encouraged her to see a primary medical doctor.  Mother has no drug or alcohol history.  Father graduated from high school, went to the Police Academy, average student.  No learning problems, no psychological problems, no drug or alcohol problems are reported.  In terms of extended family, maternal grandmother as well as maternal great grandfather have a history of depression.  Other psychiatric symptoms were denied in the family.,Mother reported that the marriage is generally okay, that there is some arguing.  She reported that it was in the normal range.,ACADEMIC BACKGROUND: , The patient attends the Roosevelt Elementary School, where he is in a regular first grade classroom with Mrs. The patient.  This is in the Kingsburg Unified School District.  No behavior problems, academic problems were reported.  He does not receive special education services.,SOCIAL HISTORY: , The patient was described as being able to make and keep friends, but at this point in time, there has been no teasing regarding smell from the encopresis.  He does have kids over to play at the house.,PREVIOUS COUNSELING:,  Denied.,DIAGNOSTIC SUMMARY AND IMPRESSION: , My impression is that the patient has a long history of constipation and impaction, which has been treated medically, but it would appear that the mother has not followed through consistently with the behavioral component of toilet sitting, increased fiber, regular medication, so that the problem has likely continued.  She also has not used any sort of rewards as a way to encourage him, in the encopresis.  The patient clearly qualifies for a diagnosis of disruptive behavior disorder, not otherwise specified, and possibly oppositional defiant disorder.  It would appear that mother needs help in her parenting, and that she tends to mostly use yelling and anger as a way, and tends to repeat herself a lot, and does not have a strategy for how to follow through and to deal with defiant behavior.  Also, mother and father, may not be on the same page in terms of parenting.,PLAN:,  In terms of my plan, I will meet with the child in the next couple of weeks.  I also asked the mother to bring the father in, so he could be involved in the treatment also, and I gave the mother a behavioral checklist to be completed by herself and the father as well as the teacher.,DSM IV DIAGNOSES:  ,AXIS I:  Adjustment disorder with disturbance of conduct (309.3).  Encopresis, without constipation, overflow incontinence (307.7),AXIS II:  No diagnoses (V71.09).,AXIS III:  No diagnoses.,AXIS IV:  Problems with primary support group.,AXIS V:  Global assessment of functioning equals 65.
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DESCRIPTION: The patient was referred due to concerns regarding behavioral acting out as well as encopresis.

consult - history and phy., developmental background, axis, dsm iv, adjustment disorder, behavioral, adjustment, depression, oppositionality, encopresis,

This situation involves a child with behavioral and encopresis (soiling) issues, which are significant concerns that can impact family dynamics and the child's well-being. However, it's not an immediate life-threatening situation, but rather an ongoing issue requiring consistent management and intervention, primarily focused on behavioral therapy and parenting support. The presence of encopresis and behavioral disturbances suggest the necessity of psychological intervention, but the stakes are not critical or urgent from a medical emergency perspective.


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

Medical Specialty: Obstetrics / Gynecology
Sample Name: Spontaneous Vaginal Delivery - 1

PREOPERATIVE DIAGNOSES,1.  Intrauterine pregnancy at 39 plus weeks gestation.,2.  Gestational hypertension.,3.  Thick meconium.,4.  Failed vacuum attempted delivery.,POSTOPERATIVE DIAGNOSES,1.  Intrauterine pregnancy at 39 plus weeks gestation.,2.  Gestational hypertension.,3.  Thick meconium.,4.  Failed vacuum attempted delivery.,OPERATION PERFORMED: , Spontaneous vaginal delivery.,ANESTHESIA: , Epidural was placed x2.,ESTIMATED BLOOD LOSS:,  500 mL.,COMPLICATIONS: , Thick meconium.  Severe variables, Apgars were 2 and 7.  Respiratory therapy and ICN nurse at delivery.  Baby went to Newborn Nursery.,FINDINGS: , Male infant, cephalic presentation, ROA.  Apgars 2 and 7.  Weight 8 pounds and 1 ounce.  Intact placenta.  Three-vessel cord.  Third degree midline tear.,DESCRIPTION OF OPERATION: , The patient was admitted this morning for induction of labor secondary to elevated blood pressure, especially for the last three weeks.  She was already 3 cm dilated.  She had artificial rupture of membranes.  Pitocin was started and she actually went to complete dilation.  While pushing, there was sudden onset of thick meconium, and she was having some severe variables and several late decelerations.  When she was complete +2, vacuum attempted delivery, three pop-offs were done.  The vacuum was then no longer used after the three pop-offs.  The patient pushed for a little bit longer and had a delivery, ROA, of a male infant, cephalic, over a third-degree midline tear.  Secondary to the thick meconium, DeLee suctioned nose and mouth before the anterior shoulder was delivered and again after delivery.  Baby was delivered floppy.  Cord was clamped x2 and cut, and the baby was handed off to awaiting ICN nurse and respiratory therapist.  Delivery of intact placenta and three-vessel cord.  Third-degree midline tear was repaired with Vicryl without any complications.  Baby initially did well and went to Newborn Nursery, where they are observing him a little bit longer there.  Again, mother and baby are both doing well.  Mother will go to Postpartum and baby is already in Newborn Nursery.
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DESCRIPTION: Spontaneous vaginal delivery.  Male infant, cephalic presentation, ROA.  Apgars 2 and 7.  Weight 8 pounds and 1 ounce.  Intact placenta.  Three-vessel cord.  Third degree midline tear.

obstetrics / gynecology, thick meconium, cephalic presentation, intrauterine pregnancy, gestational hypertension, spontaneous vaginal delivery, delivery, vaginal, placenta, newborn, meconium, apgars,

This obstetrics case involves a spontaneous vaginal delivery complicated by gestational hypertension, thick meconium, and a failed vacuum-assisted delivery attempt. Despite the complications, such as a third-degree tear and a low initial Apgar score of 2, the procedure concluded with the successful delivery of a male infant. The mention of the baby being 'floppy' and requiring immediate attention from respiratory therapy and ICN staff indicates high stakes, as there was a genuine concern for neonatal distress due to thick meconium and low Apgar. However, the situation seems to have stabilized post-delivery with the infant being observed in the Newborn Nursery, and the mother also recovered sufficiently. Given these factors, the stakes were high, primarily due to the initial distress signals during delivery.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Dilated Cardiomyopathy - Consult

REASON FOR VISIT: , I have been asked to see this 63-year-old man with a dilated cardiomyopathy by Dr. X at ABCD Hospital.  He presents with a chief complaint of heart failure.,HISTORY OF PRESENT ILLNESS: , In retrospect, he has had symptoms for the past year of heart failure.  He feels in general "OK," but is stressed and fatigued.  He works hard running 3 companies.  He has noted shortness of breath with exertion and occasional shortness of breath at rest.  There has been some PND, but he sleeps on 1 pillow.  He has no edema now, but has had some mild leg swelling in the past.  There has never been any angina and he denies any palpitations, syncope or near syncope.  When he takes his pulse, he notes some irregularity.  He follows no special diet.  He gets no regular exercise, although he has recently started walking for half an hour a day.  Over the course of the past year, these symptoms have been slowly getting worse.  He gained about 20 pounds over the past year.,There is no prior history of either heart failure or other heart problems.,His past medical history is remarkable for a right inguinal hernia repair done in 1982.  He had trauma to his right thumb.  There is no history of high blood pressure, diabetes mellitus or heart murmur.,On social history, he lives in San Salvador with his wife.  He has a lot of stress in his life.  He does not smoke, but does drink.  He has high school education.,On family history, mother is alive at age 89.  Father died at 72 of heart attack.  He has 2 brothers and 1 sister all of whom are healthy, although the oldest suffered a myocardial infarction.  He has 3 healthy girls and 9 healthy grandchildren.,A complete review of systems was performed and is negative aside from what is mentioned in the history of present illness.,MEDICATIONS: , Aspirin 81 mg daily and chlordiazepoxide and clidinium - combination pill at 5 mg/2.5 mg 1 tablet daily for stress.,ALLERGIES: , Denied.,MAJOR FINDINGS:,  On my comprehensive cardiovascular examination, he is 5 feet 8 inches and weighs 231 pounds.  His blood pressure is 120/70 in each arm seated.  His pulse is 80 beats per minute and regular.  He is breathing 1two times per minute and that is unlabored.  Eyelids are normal.  Pupils are round and reactive to light.  Conjunctivae are clear and sclerae are anicteric.  There is no oral thrush or central cyanosis.  Neck is supple and symmetrical without adenopathy or thyromegaly.  Jugular venous pressure is normal.  Carotids are brisk without bruits.  Lungs are clear to auscultation and percussion.  The precordium is quiet.  The rhythm is regular.  The first and second heart sounds are normal.  He does have a fourth heart sound and a soft systolic murmur.  The precordial impulse is enlarged.  Abdomen is soft without hepatosplenomegaly or masses.  He has no clubbing, cyanosis or peripheral edema.  Distal pulses are normal throughout both arms and both legs.  On neurologic examination, his mentation is normal.  His mood and affect are normal.  He is oriented to person, place, and time.,DATA: , His EKG shows sinus rhythm with left ventricular hypertrophy.,A metabolic stress test shows that he was able to exercise for 5 minutes and 20 seconds to 90% of his maximum predicted heart rate.  His peak oxygen consumption was 19.7 mL/kg/min, which is consistent with mild cardiopulmonary disease.,Laboratory data shows his TSH to be 1.33.  His glucose is 97 and creatinine 0.9.  Potassium is 4.3.  He is not anemic.  Urinalysis was normal.,I reviewed his echocardiogram personally.  This shows a dilated cardiomyopathy with EF of 15%.  The left ventricular diastolic dimension is 6.8 cm.  There are no significant valvular abnormalities.,He had a stress thallium.  His heart rate response to stress was appropriate.  The thallium images showed no scintigraphic evidence of stress-induced myocardial ischemia at 91% of his maximum age predicted heart rate.  There is a fixed small sized mild-to-moderate intensity perfusion defect in the distal inferior wall and apex, which may be an old infarct, but certainly does not account for the degree of cardiomyopathy.  We got his post-stress EF to be 33% and the left ventricular cavity appeared to be enlarged.  The total calcium score will put him in the 56 percentile for subjects of the same age, gender, and race/ethnicity.,ASSESSMENTS: , This appears to be a newly diagnosed dilated cardiomyopathy, the etiology of which is uncertain.,PROBLEMS DIAGNOSES:  ,1.  Dilated cardiomyopathy.,2.  Dyslipidemia.,PROCEDURES AND IMMUNIZATIONS: , None today.,PLANS: , I started him on an ACE inhibitor, lisinopril 2.5 mg daily, and a beta-blocker, carvedilol 3.125 mg twice daily.  The dose of these drugs should be up-titrated every 2 weeks to a target dose of lisinopril of 20 mg daily and carvedilol 25 mg twice daily.  In addition, he could benefit from a loop diuretic such as furosemide.  I did not start this as he is planning to go back home to San Salvador tomorrow.  I will leave that up to his local physicians to up-titrate the medications and get him started on some furosemide.,In terms of the dilated cardiomyopathy, there is not much further that needs to be done, except for family screening.  All of his siblings and his children should have an EKG and an echocardiogram to make sure they have not developed the same thing.  There is a strong genetic component of this.,I will see him again in 3 to 6 months, whenever he can make it back here.  He does not need a defibrillator right now and my plan would be to get him on the right doses of the right medications and then recheck an echocardiogram 3 months later.  If his LV function has not improved, he does have New York Heart Association Class II symptoms and so he would benefit from a prophylactic ICD.,Thank you for asking me to participate in his care.,MEDICATION CHANGES:,  See the above.
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DESCRIPTION: A 63-year-old man with a dilated cardiomyopathy presents with a chief complaint of heart failure.  He has noted shortness of breath with exertion and occasional shortness of breath at rest.

The situation involves a patient with newly diagnosed dilated cardiomyopathy, which is a serious heart condition that causes heart failure symptoms. The patient's ejection fraction is notably low at 15%, indicating severe heart impairment. The management involves starting and up-titrating important heart medications, and close follow-up is planned. While he does not currently need a defibrillator, this could change depending on his response to treatment, indicating potential future high-risk interventions. The condition is serious and impacts his overall health and life expectancy, making the situation high-stakes from a medical perspective.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: CT Chest

TECHNIQUE: , Sequential axial CT images were obtained from the base of the brain to the upper abdomen following the uneventful administration of 100cc Optiray 350 intravenous contrast.,FINDINGS: , The heart size is normal and there is no pericardial effusion.  The aorta and great vessels are normal in caliber.  The central pulmonary arteries are patent with no evidence of embolus.  There is no significant mediastinal, hilar, or axillary lymphadenopathy.  The trachea and mainstem bronchi are patent.  The esophagus is normal in course and caliber.  The lungs are clear with no infiltrates, effusions, or masses.  There is no pneumothorax.  Scans through the upper abdomen are unremarkable.  The osseous structures in the chest are intact.  ,IMPRESSION: , No acute abnormalities.
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DESCRIPTION: Common CT Chest template

Common CT Chest template

cardiovascular / pulmonary, sequential axial ct images, optiray, pericardial effusion, mediastinal, hilar, axillary, lymphadenopathy, ct chest, upper abdomenNOTE

The CT Chest report describes a routine imaging examination with normal findings and no acute abnormalities. This scenario does not involve any immediate health crises or decisions requiring urgent intervention, making it low-stakes in nature. There is no mention of any critical condition or impending health risk based on the imaging results.


Medical Specialty: Consult - History and Phy.
Sample Name: Normal Male ROS Template - 1

REVIEW OF SYSTEMS:,CONSTITUTIONAL:  Patient denies fevers, chills, sweats and weight changes.,EYES:  Patient denies any visual symptoms.,EARS, NOSE, AND THROAT:  No difficulties with hearing.  No symptoms of rhinitis or sore throat.,CARDIOVASCULAR:  Patient denies chest pains, palpitations, orthopnea and paroxysmal nocturnal dyspnea.,RESPIRATORY:  No dyspnea on exertion, no wheezing or cough.,GI:  No nausea, vomiting, diarrhea, constipation, abdominal pain, hematochezia or melena.,GU:  No urinary hesitancy or dribbling.  No nocturia or urinary frequency.  No abnormal urethral discharge.,MUSCULOSKELETAL:  No myalgias or arthralgias.,NEUROLOGIC:  No chronic headaches, no seizures.  Patient denies numbness, tingling or weakness.,PSYCHIATRIC:  Patient denies problems with mood disturbance.  No problems with anxiety.,ENDOCRINE:  No excessive urination or excessive thirst.,DERMATOLOGIC:  Patient denies any rashes or skin changes.
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DESCRIPTION: An example/template for a routine normal male ROS.

consult - history and phy., review of systems, normal male ros, normal male, male ros, male, ros, throat, urinary

The Review of Systems (ROS) template provided is a standard medical checklist used to document a patient's reported symptoms across various bodily systems. The situation involves the completion and use of a form that records a patient's health status based on their self-reported observations. This is a typical and routine part of medical assessments, especially in annual physical exams or initial consultations, and does not involve immediate decision-making that could impact someone's health critically. Since there are no indicated issues in the ROS, and this is presented as a template example for routine use, it does not present any urgency or high-stakes decision-making.


Medical Specialty: Dentistry
Sample Name: Teeth Extraction & I&D - 1

PREOPERATIVE DIAGNOSES: , Carious teeth #2 and #19 and left mandibular dental abscess.,POSTOPERATIVE DIAGNOSES:,  Carious teeth #2 and #19 and left mandibular dental abscess.,PROCEDURES:,  Extraction of teeth #2 and #19 and incision and drainage of intraoral and extraoral of left mandibular dental abscess.,ANESTHESIA: , General, oral endotracheal.,COMPLICATIONS: , None.,DRAINS: , Penrose 0.25 inch intraoral and vestibule and extraoral.,CONDITION:,  Stable to PACU.,DESCRIPTION OF PROCEDURE:,  Patient was brought to the operating room, placed on the table in the supine position and after demonstration of an adequate plane of general anesthesia via the oral endotracheal route, patient was prepped and draped in the usual fashion for an intraoral procedure.  In addition, the extraoral area on the left neck was prepped with Betadine and draped accordingly.  Gauze throat pack was placed and local anesthetic was administered in the left lower quadrant, total of 3.4 mL of lidocaine 2% with 1:100,000 epinephrine and Marcaine 1.7 mL of 0.5% with 1:200,000 epinephrine.  An incision was made with #15 blade in the left submandibular area through the skin and blunt dissection was accomplished with curved mosquito hemostat to the inferior border of the mandible.  No purulent drainage was obtained.  The 0.25 inch Penrose drain was then placed in the extraoral incision and it was secured with 3-0 silk suture.  Moving to the intraoral area, periosteal elevator was used to elevate the periosteum from the buccal aspect of tooth #19.  The area did not drain any purulent material.  The carious tooth #19 was then extracted by elevator and forceps extraction.  After the tooth was removed, the 0.25 inch Penrose drain was placed in a subperiosteal fashion adjacent to the extraction site and secured with 3-0 silk suture.  The tube was then repositioned to the left side allowing access to the upper right quadrant where tooth #2 was then extracted by routine elevator and forceps extraction.  After the extraction, the throat pack was removed.  An orogastric tube was then placed by Dr. X, and stomach contents were suctioned.  The pharynx was then suctioned with the Yankauer suction.  The patient was awakened, extubated, and taken to the PACU in stable condition.
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DESCRIPTION: Extraction of teeth #2 and #19 and incision and drainage (I&D) of intraoral and extraoral of left mandibular dental abscess.

dentistry, yankauer suction, orogastric tube, carious teeth, penrose drain, forceps extraction, dental abscess, incision, elevator, mandibular, dental, abscess, teeth, intraoral, extraction, drainage,

The procedure described involves the extraction of carious teeth and management of a dental abscess, which is common in dental practice. The patient was under general anesthesia, indicating a more involved procedure than basic dental surgery done under local anesthesia. However, this kind of procedure is considered routine within oral surgery and does not typically involve high risk. The absence of complications and the patient's stable condition post-operation further reduce the stakes. Despite the use of general anesthesia, which adds some risk, it remains a standard protocol under control. Therefore, while it is certainly not without risks—such as those associated with anesthesia and infection control—these are anticipated and managed risks in a controlled environment.


Medical Specialty: Radiology
Sample Name: MRI Brain - Memory Loss

FINDINGS:,There is moderate to severe generalized neuronal loss of the cerebral hemispheres with moderate to severe ventricular enlargement and prominent CSF within the subarachnoid spaces. There is confluent white matter hyperintensity in a bi-hemispherical centrum semiovale distribution extending to the lateral ventricles consistent with severe vasculopathic small vessel disease and extensive white matter ischemic changes. There is normal enhancement of the dural sinuses and cortical veins and there are no enhancing intra-axial or extraaxial mass lesions. There is a cavum velum interpositum (normal variant).,There is a linear area of T1 hypointensity becoming hyperintense on T2 images in a left para-atrial trigonal region representing either a remote lacunar infarction or prominent perivascular space.,Normal basal ganglia and thalami. Normal internal and external capsules. Normal midbrain.,There is amorphus hyperintensity of the basis pontis consistent with vasculopathic small vessel disease. There are areas of T2 hyperintensity involving the bilateral brachium pontis (left greater than right) with no enhancement following gadolinium augmentation most compatible with areas of chronic white matter ischemic changes. The area of white matter signal alteration in the left brachium pontis is of some concern in that is has a round morphology. Interval reassessment of this lesion is recommended.,There is a remote lacunar infarction of the right cerebellar hemisphere. Normal left cerebellar hemisphere and vermis.,There is increased CSF within the sella turcica and mild flattening of the pituitary gland but no sellar enlargement. There is elongation of the basilar artery elevating the mammary bodies but no dolichoectasia of the basilar artery.,Normal flow within the carotid arteries and circle of Willis.,Normal calvarium, central skull base and temporal bones.  There is no demonstrated calvarium metastases.,IMPRESSION:,Severe generalized cerebral atrophy.,Extensive chronic white matter ischemic changes in a bi-hemispheric centrum semiovale distribution with involvement of the basis pontis and probable bilateral brachium pontis. The area of white matter hyperintensity in the left brachium pontis is of some concern is that it has a round morphology but no enhancement following gadolinium augmentation. Interval reassessment of this lesion is recommended.,Remote lacunar infarction in the right cerebellar hemisphere.,Linear signal alteration of the left periatrial trigonal region representing either a prominent vascular space or,lacunar infarction.,No demonstrated calvarial metastases.
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DESCRIPTION: A middle-aged female with memory loss.

A middle-aged female with memory loss.

radiology, white matter ischemic, remote lacunar infarction, memory loss, matter ischemic, remote lacunar, cerebellar hemisphere, lacunar infarction, brachium pontis, white matter, basilar, calvarium, ischemic, enhancement, cerebellar, hemispheres, hyperintensity, infarction, brachium,

The findings from the MRI and impression indicate severe generalized cerebral atrophy and extensive chronic white matter ischemic changes. These findings are concerning and could explain the memory loss in the middle-aged female patient. The possibility of a round morphology lesion raises further concern, and a reassessment is recommended, which adds to the seriousness of the situation. While there is no immediate life-threatening condition like calvarial metastases, the neurologic implications are significant and warrant further investigation and management. Therefore, given the potential implications for the patient's brain health and cognitive function, this situation is considered high-stakes.


Medical Specialty: Hematology - Oncology
Sample Name: Biopsy - Axillary Lymph Node

PREOPERATIVE DIAGNOSES:,1.  Right axillary adenopathy.,2.  Thrombocytopenia.,3.  Hepatosplenomegaly.,POSTOPERATIVE DIAGNOSES:,1.  Right axillary adenopathy.,2.  Thrombocytopenia.,3.  Hepatosplenomegaly.,PROCEDURE PERFORMED:  ,Right axillary lymph node biopsy.,ANESTHESIA: , Local with sedation.,COMPLICATIONS: , None.,DISPOSITION: , The patient tolerated the procedure well and was transferred to the recovery room in stable condition.,BRIEF HISTORY:  ,The patient is a 37-year-old male who presented to ABCD General Hospital secondary to hiccups and was ultimately found to have a right axillary mass to be severely thrombocytopenic with a platelet count of 2000 as well as having hepatosplenomegaly.  The working diagnosis is lymphoma, however, the Hematology and Oncology Departments were requesting a lymph node biopsy in order to confirm the diagnosis as well as prognosis.  Thus, the patient was scheduled for a lymph node biopsy with platelets running secondary to thrombocytopenia at the time of surgery.,INTRAOPERATIVE FINDINGS: , The patient was found to have a large right axillary lymphadenopathy, one of the lymph node was sent down as a fresh specimen.,PROCEDURE:  ,After informed written consent, risks and benefits of this procedure were explained to the patient.  The patient was brought to the operating suite, prepped and draped in a normal sterile fashion.  Multiple lymph nodes were palpated in the right axilla, however, the most inferior node was to be removed.  First, the skin was anesthetized with 1% lidocaine solution.  Next, using a #15 blade scalpel, an incision was made approximately 4 cm in length transversally in the inferior axilla.  Next, using electro Bovie cautery, maintaining hemostasis, dissection was carried down to the lymph node.  The lymph node was then completely excised using electro Bovie cautery as well as hemostats to maintain hemostasis and then lymph node was sent to specimen fresh to the lab.  Several hemostats were used, suture ligated with #3-0 Vicryl suture and hemostasis was maintained.  Next the deep dermal layers were approximated with #3-0 Vicryl suture.  After the wound has been copiously irrigated, the skin was closed with running subcuticular #4-0 undyed Vicryl suture and the pathology is pending.  The patient did tolerated the procedure well.  Steri-Strips and sterile dressings were applied and the patient was transferred to the Recovery in stable condition.
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DESCRIPTION: Right axillary adenopathy, thrombocytopenia, and hepatosplenomegaly.  Right axillary lymph node biopsy.

hematology - oncology, hepatosplenomegaly, thrombocytopenia, axillary adenopathy, axillary lymph node biopsy, axillary lymph node, lymph node biopsy, lymph node, lymph, node, axillary, adenopathy, hemostasis, suture, biopsy,

The situation involves a medical procedure, specifically a biopsy of the axillary lymph node, to diagnose a potentially serious condition such as lymphoma. The stakes are high because the outcome of the biopsy can significantly impact the patient's course of treatment and prognosis. Furthermore, the patient has severe thrombocytopenia, which is a condition that can complicate surgical procedures due to increased risk of bleeding. Luckily, no complications occurred during the procedure, and the patient is stable. Despite the successful procedure, the process itself, and especially the waiting for biopsy results, is high-stakes due to the potential implications of the diagnosis.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Radionuclide Stress Test

INDICATION FOR STUDY: , Elevated cardiac enzymes, fullness in chest, abnormal EKG, and risk factors.,MEDICATIONS:,  Femara, verapamil, Dyazide, Hyzaar, glyburide, and metformin.,BASELINE EKG: , Sinus rhythm at 84 beats per minute, poor anteroseptal R-wave progression, mild lateral ST abnormalities.,EXERCISE RESULTS:,1.  The patient exercised for 3 minutes stopping due to fatigue.  No chest pain.,2.  Heart rate increased from 84 to 138 or 93% of maximum predicted heart rate.  Blood pressure rose from 150/88 to 210/100.  There was a slight increase in her repolorization abnormalities in a non-specific pattern.,NUCLEAR PROTOCOL:  ,Same day rest/stress protocol was utilized with 11 mCi for the rest dose and 33 mCi for the stress test.,NUCLEAR RESULTS:,1.  Nuclear perfusion imaging, review of the raw projection data reveals adequate image acquisition.  The resting images showed decreased uptake in the anterior wall.  However the apex is spared of this defect.  There is no significant change between rest and stress images.  The sum score is 0.,2.  The Gated SPECT shows moderate LVH with slightly low EF of 48%.,IMPRESSION:,1.  No evidence of exercise induced ischemia at a high myocardial workload.  This essentially excludes obstructive CAD as a cause of her elevated troponin.,2.  Mild hypertensive cardiomyopathy with an EF of 48%.,3.  Poor exercise capacity due to cardiovascular deconditioning.,4.  Suboptimally controlled blood pressure on today's exam.
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DESCRIPTION: Elevated cardiac enzymes, fullness in chest, abnormal EKG, and risk factors.  No evidence of exercise induced ischemia at a high myocardial workload.  This essentially excludes obstructive CAD as a cause of her elevated troponin.

cardiovascular / pulmonary, sinus rhythm, cardiac enzymes, abnormal ekg, stress test, elevated troponin, heart rate, blood pressure, radionuclide, chest, ekg, stress, ischemia

The situation involves evaluating a patient's cardiovascular condition using a radionuclide stress test. The test results provide important information about the patient's heart function, confirm the presence of mild hypertensive cardiomyopathy, and highlight issues such as poor exercise capacity and suboptimally controlled blood pressure. While the immediate test results exclude obstructive coronary artery disease (CAD) as a cause of elevated troponin, the findings still indicate significant cardiovascular concerns needing management. Therefore, the situation is moderate in stakes because it involves critical health parameters but doesn't indicate an immediate life-threatening emergency.


Medical Specialty: Consult - History and Phy.
Sample Name: Neurologic Consultation - 4

REASON FOR NEUROLOGICAL CONSULTATION:,  Muscle twitching, clumsiness, progressive pain syndrome, and gait disturbance.,HISTORY OF PRESENT ILLNESS: , The patient is a 62-year-old African-American male with a significant past medical history of diabetes, hypertension, previous stroke in 2002 with minimal residual right-sided weakness as well as two MIs, status post pacemaker insertion who first presented with numbness in his lower extremities in 2001.  He states that since that time these symptoms have been progressive and now involving his legs above his knees as well as his hands.  More recently, he describes a burning sensation along with numbness.  This has become a particular problem and of all the problems he has he feels that pain is his primary concern.  Over the last six months, he has noticed that he cannot feel hot objects in his hands and that objects slip out of his hands.  He denies any weakness per se, just clumsiness and decreased sensation.  He has also been complaining of brief muscle jerks, which occur in both hands and his shoulders.  This has been a fairly longstanding problem, and again has become more prevalent recently.  He does not have any tremor.  He denies any neck pain.  He walks with the aid of a walker because of unsteadiness with gait.,Recently, he has tried gabapentin, but this was not effective for pain control.  Oxycodone helps somewhat and gives him at least three hours pain relief.  Because of the pain, he has significant problems with fractured sleep.  He states he has not had a good night's sleep in many years.  About six months ago, after an MI and pacemaker insertion, he was transferred to a nursing facility.  At that facility, his insulin was stopped.  Since then he has only been on oral medication for his diabetes.  He denies any back pain, neck pain, change in bowel or bladder function, or specific injury pre-dating these symptoms., ,PAST MEDICAL HISTORY: , Diabetes, hypertension, coronary artery disease, stroke, arthritis, GERD, and headaches.,MEDICATIONS: , Trazodone, simvastatin, hydrochlorothiazide, Prevacid, lisinopril, glipizide, and gabapentin.,FAMILY HISTORY: , Discussed above and documented on the chart.,SOCIAL HISTORY: , Discussed above and documented on the chart.  He does not smoke.  He lives in a senior citizens building with daily nursing aids.  He previously was a security guard, but is currently on disability.,REVIEW OF SYSTEMS: , Discussed above and documented on the chart.,PHYSICAL EXAMINATION: , On examination, blood pressure 150/80, pulse of 80, respiratory rate 22, and weight 360 pounds.  Pain scale 7/10.  A full general and neurological examination was performed on the patient and is documented on the chart.,The patient is obese with significant ankle edema.,Neurological examination reveals normal cognitive exam and normal cranial nerve examination.  Motor examination reveals mild atrophy in bilateral FDIs, but still has a strong grip.  Individual muscle strength is close to normal with only subtle weakness found in ankle plantar and dorsiflexion.  Tone and bulk are normal.  Sensory examination reveals a severe decrease to all modalities in his lower extremities from just above the knees distally.  He has no vibration sense at his knees.  Similarly, there is decrease to all sensory modalities in his both upper extremities from just above the wrist distally.  The only reflexes I could obtain with trace reflexes in his biceps.  Remaining reflexes were unelicitable.  No Babinski.  The patient walks normally with the aid of a cane.  He has severe sensory ataxia with inability to walk unaided.  Positive Romberg with eyes open and closed.,IMPRESSION AND PLAN:,1.  Probable painful diabetic neuropathy.  Symptoms are predominantly sensory and severely dysfunctioning, with the patient having inability to ambulate independently as well as difficulty with grip and temperature differentiation in his upper extremities.  He has relative preservation of motor function.  Because these symptoms are progressive and, by report, he came off his insulin, suggesting somewhat mild diabetes, I would like to rule out other causes of progressive neuropathy.,2.  He has history of myoclonic jerks.  I did not see any on my examination today and I feel that these are benign and probably secondary to his severe insomnia, which he states is secondary to the painful neuropathy.  I would like to rule out other causes such as hepatic encephalopathy., ,I have recommended the following:,1.  EMG/nerve conduction study to assess severity of neuropathy and to characterize neuropathy.,2.  Blood work, looking for other causes of neuropathy and myoclonus, to include CBC, CMP, TSH, LFT, B12, RPR, ESR, Lyme titer, and HbA1c, and ammonia level.,3.  Neurontin and oxycodone have not been effective, and I have recommended Cymbalta starting at 30 mg q.d. for five days and then increasing to 60 mg q.d.  Side effect profile of this medication was discussed with the patient.,4.  I have explained to him that progression of diabetic neuropathy is closely related to diabetic control and I have recommended tight diabetic control.,5.  I will see him at followup at the EMG.
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DESCRIPTION: Muscle twitching, clumsiness, progressive pain syndrome, and gait disturbance.  Probable painful diabetic neuropathy.  Symptoms are predominantly sensory and severely dysfunctioning, with the patient having inability to ambulate independently as well as difficulty with grip and temperature differentiation in his upper extremities.

The scenario involves a complex medical assessment of a patient with multiple serious health conditions, including diabetes, hypertension, history of strokes, myocardial infarctions, and now probable painful diabetic neuropathy with progressive sensory dysfunction. This assessment is high-stakes due to the potential for severe quality of life impact, the need for accurate diagnosis and treatment adjustments to prevent further progression, and the management of comorbid conditions. The stakes are elevated further by the patient's history of non-trivial procedural interventions, such as pacemaker insertion, that could be influenced by his current neurological status.


Medical Specialty: Surgery
Sample Name: Nephrectomy - Radical

PREOPERATIVE DIAGNOSIS: , Right renal mass.,POSTOPERATIVE DIAGNOSIS: , Right renal mass.,PROCEDURE: , Right radical nephrectomy and assisted laparoscopic approach.,ANESTHESIA:  ,General.,PROCEDURE IN DETAIL:  ,The patient underwent general anesthesia with endotracheal intubation.  An orogastric was placed and a Foley catheter placed.  He was placed in a modified flank position with the hips rotated to 45 degrees.  Pillow was used to prevent any pressure points.  He was widely shaved, prepped, and draped.  A marking pen was used to delineate a site for the Pneumo sleeve in the right lower quadrant and for the trocar sites in the midline just above the umbilicus and halfway between the xiphoid and the umbilicus.  The incision was made through the premarked site through the skin and subcutaneous tissue.  The aponeurosis of the external oblique was incised in the direction of its fibers.  Muscle-splitting incision was made in the internal oblique and transversus abdominis.  The peritoneum was opened and the Pneumo sleeve was placed in the usual fashion being sure that no bowel was trapped inside the ring.  Then, abdominal insufflation was carried out through the Pneumo sleeve and the scope was passed through the Pneumo sleeve to visualize placement of the trocars in the other two positions.  Once this had been completed, the scope was placed in the usual port and dissection begun by taking down the white line of Toldt, so that the colon could be retracted medially.  This exposed the duodenum, which was gently swept off the inferior vena cava and dissection easily disclosed the takeoff of the right renal vein off the cava.  Next, attention was directed inferiorly and the ureter was divided between clips and the inferior tongue of Gerota fascia was taken down, so that the psoas muscle was exposed.  The attachments lateral to the kidney was taken down, so that the kidney could be flipped anteriorly and medially, and this helped in exposing the renal artery.  The renal artery had been previously noticed on the CT scan to branch early and so each branch was separately ligated and divided using the stapler device.  After the arteries had been divided, the renal vein was divided again using a stapling device.  The remaining attachments superior to the kidney were divided with the Harmonic scalpel and also utilized the stapler, and the specimen was removed.  Reexamination of the renal fossa at low pressures showed a minimal degree of oozing from the adrenal gland, which was controlled with Surgicel.  Next, the port sites were closed with 0 Vicryl utilizing the passer and doing it over the hand to prevent injury to the bowel and the right lower quadrant incision for the hand port was closed in the usual fashion.  The estimated blood loss was negligible.  There were no complications.  The patient tolerated the procedure well and left the operating room in satisfactory condition.
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DESCRIPTION: Right radical nephrectomy and assisted laparoscopic approach.

surgery, renal mass, foley catheter, gerota fascia, muscle-splitting incision, pneumo sleeve, endotracheal, laparoscopic, nephrectomy, orogastric, renal fossa, right lower quadrant, trocar, umbilicus, vena cava, renal, pneumo, radical,

The situation involves a radical nephrectomy, a major surgical procedure to remove a kidney due to conditions such as a renal mass which could be cancerous. The surgical details provided indicate the use of general anesthesia, control of vascular structures, and careful postoperative examination to ensure minimal complications. Given the complexity and potential life-impacting nature of the condition being addressed (e.g., cancer), this procedure is high-stakes due to the risks involved and its implications for the patient's health.


Medical Specialty: Surgery
Sample Name: Flexor Carpi Radialis & Palmaris Longus Repair

PREOPERATIVE DIAGNOSIS:,  Right wrist laceration with a flexor carpi radialis laceration and palmaris longus laceration 90%, suspected radial artery laceration.,POSTOPERATIVE DIAGNOSIS:,  Right wrist laceration with a flexor carpi radialis laceration and palmaris longus laceration 90%, suspected radial artery laceration.,PROCEDURES PERFORMED:  ,1.  Repair flexor carpi radialis.,2.  Repair palmaris longus.,ANESTHETIC: , General.,TOURNIQUET TIME:  ,Less than 30 minutes.,CLINICAL NOTE:  ,The patient is a 21-year-old who sustained a clean laceration off a teapot last night.  She had lacerated her flexor carpi radialis completely and 90% of her palmaris longus.  Both were repaired proximal to the carpal tunnel.  The postoperative plans are for a dorsal splint and early range of motion passive and active assist.  The wrist will be at approximately 30 degrees of flexion.  The MPJ is at 30 degrees of flexion, the IP straight.  Splinting will be used until the 4-week postoperative point.,PROCEDURE: , Under satisfactory general anesthesia, the right upper extremity was prepped and draped in the usual fashion.  There were 2 transverse lacerations.  Through the first laceration, the flexor carpi radialis was completely severed.  The proximal end was found with a tendon retriever.  The distal end was just beneath the subcutaneous tissue.,A primary core stitch was used with a Kessler stitch.  This was with 4-0 FiberWire.  A second core stitch was placed, again using 4-0 FiberWire.  The repair was oversewn with locking, running, 6-0 Prolene stitch.  Through the second incision, the palmaris longus was seen to be approximately 90% severed.  It was an oblique laceration.  It was repaired with a 4-0 FiberWire core stitch and with a Kessler-type stitch.  A secure repair was obtained.  She was dorsiflexed to 75 degrees of wrist extension without rupture of the repair.  The fascia was released proximally and distally to give her more room for excursion of the repair.,The tourniquet was dropped, bleeders were cauterized.  Closure was routine with interrupted 5-0 nylon.  A bulky hand dressing as well as a dorsal splint with the wrist MPJ and IP as noted.  The splint was dorsal.  The patient was sent to the recovery room in good condition.
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DESCRIPTION: Flexor carpi radialis and palmaris longus repair.  Right wrist laceration with a flexor carpi radialis laceration and palmaris longus laceration 90%, suspected radial artery laceration.

surgery, kessler stitch, flexor carpi radialis, palmaris longus, radialis, laceration, fiberwire, flexor, carpi, palmaris, longus, repair

The scenario involves a surgical procedure to repair significant tendon lacerations in the wrist, which are quite serious and require surgical intervention. The suspected radial artery laceration adds potential complications, as it may affect blood flow to the hand. While the procedure appears to have been conducted successfully and the postoperative prognosis seems positive, the potential impact on the patient's hand function and the complexity of the surgery indicate that this is a high-stakes procedure. Such surgeries carry risks such as infection, poor wound healing, and the need for further surgery. Therefore, it is critical to ensure the surgery is performed correctly to restore function and prevent complications.


Medical Specialty: Gastroenterology
Sample Name: Esophagogastroduodenoscopy - 13

PROCEDURE PERFORMED: , Esophagogastroduodenoscopy performed in the emergency department.,INDICATION: , Melena, acute upper GI bleed, anemia, and history of cirrhosis and varices.,FINAL IMPRESSION,1.  Scope passage massive liquid in stomach with some fresh blood near the fundus, unable to identify source due to gastric contents.,2.  Endoscopy following erythromycin demonstrated grade I esophageal varices.  No stigmata of active bleeding.  Small amount of fresh blood within the hiatal hernia.  No definite source of bleeding seen.,PLAN,1.  Repeat EGD tomorrow morning following aggressive resuscitation and transfusion.,2.  Proton-pump inhibitor drip.,3.  Octreotide drip.,4.  ICU bed.,PROCEDURE DETAILS:  ,Prior to the procedure, physical exam was stable.  During the procedure, vital signs remained within normal limits.  Prior to sedation, informed consent was obtained.  Risks, benefits, and alternatives including, but not limited to risk of bleeding, infection, perforation, adverse reaction to medication, failure to identify pathology, pancreatitis, and death explained to the patient and his wife, who accepted all risks.  The patient was prepped in the left lateral position.  IV sedation was given to a total of fentanyl 100 mcg and midazolam 4 mg for the initial EGD.  An additional 50 mcg of fentanyl and 2 mg of midazolam were given following erythromycin.  Scope tip of the Olympus gastroscope was passed into the esophagus.  Proximal, middle, and distal thirds of the esophagus were well visualized.  There was fresh blood in the esophagus, which was washed thoroughly, but no source was seen.  No evidence of varices was seen.  The stomach was entered.  The stomach was filled with very large clot and fresh blood and liquid, which could not be suctioned due to the clot burden.  There was a small amount of bright red blood near the fundus, but a source could not be identified due to the clot burden.  Because of this, the gastroscope was withdrawn.  The patient was given 250 mg of erythromycin in the Emergency Department and 30 minutes later, the scope was repassed.  On the second look, the esophagus was cleared.  The liquid gastric contents were cleared.  There was still a moderate amount of clot burden in the stomach, but no active bleeding was seen.  There was a small grade I esophageal varices, but no stigmata of bleed.  There was also a small amount of fresh blood within the hiatal hernia, but no source of bleeding was identified.  The patient was hemodynamically stable; therefore, a decision was made for a second look in the morning.  The scope was withdrawn and air was suctioned.  The patient tolerated the procedure well and was sent to recovery without immediate complications.
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DESCRIPTION: Esophagogastroduodenoscopy performed in the emergency department.

gastroenterology, gi bleed, anemia, cirrhosis, stomach, fundus, hiatal hernia, esophagogastroduodenoscopy, erythromycin, varices, esophagus,

The situation involves a medical procedure on a patient with indications of a potentially life-threatening condition such as an acute upper GI bleed and a history of cirrhosis and varices. The patient is in the emergency department, requiring urgent care and close monitoring, including a plan for aggressive resuscitation and ICU admission, which indicates a high-risk situation with significant potential consequences for the patient's health outcomes.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Ultrasound OB

REASON FOR EXAM: , Followup for fetal growth. , ,INTERPRETATION: , Real-time exam demonstrates a single intrauterine fetus in cephalic presentation with a regular cardiac rate of 147 beats per minute documented. ,FETAL BIOMETRY:  ,BPD = 8.3 cm = 33 weeks, 4 days,HC = 30.2 cm = 33 weeks, 4 days,AC = 27.9 cm = 32 weeks, 0 days,FL =  6.4 cm = 33 weeks, 1 day,The head to abdomen circumference ratio is normal at 1.08, and the femur length to abdomen circumference ratio is normal at 23.0%.  Estimated fetal weight is 2,001 grams.  ,The amniotic fluid volume appears normal, and the calculated index is normal for the age at 13.7 cm.  ,A detailed fetal anatomic exam was not performed at this setting, this being a limited exam for growth.  The placenta is posterofundal and grade 2., ,IMPRESSION: , Single viable intrauterine pregnancy in cephalic presentation with a composite gestational age of 32 weeks, 5 days, plus or minus 17 days, giving and estimated date of confinement of 8/04/05.  There has been normal progression of fetal growth compared to the two prior exams of 2/11/05 and 4/04/05.  The examination of 4/04/05 questioned an echogenic focus within the left ventricle.  The current examination does not demonstrate any significant persistent echogenic focus involving the left ventricle.
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DESCRIPTION: Ultrasound OB - followup for fetal growth.

obstetrics / gynecology, amniotic fluid volume, placenta, posterofundal, intrauterine pregnancy, followup for fetal growth, ultrasound ob, cephalic presentation, abdomen circumference, circumference ratio, echogenic focus, fetal growth, fetal,

This ultrasound report is for a follow-up on fetal growth, which is routine in obstetrics, especially to monitor the development and health of the fetus. The results indicate normal parameters for gestational age and no significant abnormalities. While monitoring fetal growth is important, the findings do not suggest immediate life-threatening issues, making it medium stakes rather than high stakes.


Medical Specialty: Neurosurgery
Sample Name: Anterior Cervical Discectomy & Interbody Fusion - 3

PREOPERATIVE DIAGNOSES:,  ,1.  Spondylosis with cervical stenosis C5-C6 greater than C4-C5, C6-C7, (721.0, 723.0).,2.  Neck pain with left radiculopathy, progressive (723.1/723.4).,3.  Headaches, progressive (784.0).,POSTOPERATIVE DIAGNOSES:,  ,1.  Spondylosis with cervical stenosis C5-C6 greater than C4-C5, C6-C7, (721.0, 723.0).,2.  Neck pain with left radiculopathy, progressive (723.1/723.4).,3.  Headaches, progressive (784.0).,PROCEDURES:,  ,1.  Anterior cervical discectomy at C5-C6 for neural decompression (63075).,2.  Anterior interbody fusion C5-C6 (22554) utilizing Bengal cage (22851).,3.  Anterior cervical instrumentation at C5-C6 for stabilization by Uniplate construction at C5-C6 (22845); with intraoperative x-ray x2.,SERVICE:  ,  Neurosurgery,ANESTHESIA:,
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DESCRIPTION: Anterior cervical discectomy for neural decompression and anterior interbody fusion C5-C6 utilizing Bengal cage.

neurosurgery, spondylosis, neck pain, headaches, decompression, uniplate, anterior cervical discectomy, neural decompression, cervical stenosis, prevertebral space, antibiotic solution, cervical discectomy, interbody fusion, bengal cage, interbody, anterior, cervical, discectomy,

The described procedure involves anterior cervical discectomy and fusion, which is a significant neurosurgical operation typically employed to relieve spinal cord or nerve root compression. This is a high-stakes surgery because it poses risks such as nerve damage, infection, and potential further spinal issues if not performed accurately. Additionally, the stakes are higher due to the progressive nature of the preoperative conditions involving neck pain and headaches, highlighting an urgent need for intervention to prevent worsening symptoms.


Medical Specialty: Surgery
Sample Name: Laparoscopic Cholecystectomy

The patient's abdomen was prepped and draped in the usual sterile fashion.  A subumbilical skin incision was made.  The Veress needle was inserted, and the patient's abdominal cavity was insufflated with moderate pressure all times.  A subumbilical trocar was inserted.  The camera was inserted in the panoramic view.  The abdomen demonstrated some inflammation around the gallbladder.  A 10-mm midepigastric trocar was inserted.  A. 2 mm and 5 mm trocars were inserted.  The most lateral trocar grasping forceps was inserted and grasped the fundus of the gallbladder and placed in tension at liver edge.,Using the dissector, the cystic duct was identified and double Hemoclips were invited well away from the cystic-common duct junction.  The cystic artery was identified and double Hemoclips applied.  The gallbladder was taken down from the liver bed using Endoshears and electrocautery.  Hemostasis was obtained.  The gallbladder was removed from the midepigastric trocar site without difficulty.  The trocars were removed and the skin incisions were reapproximated using 4-0 Monocryl.  Steri-Strips and sterile dressing were placed.  The patient tolerated the procedure well and was taken to the recovery room in stable condition.
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DESCRIPTION: Standard Laparoscopic Cholecystectomy Operative Note.

surgery, gallbladder, laparoscopic cholecystectomy, midepigastric trocar, double hemoclips, laparoscopic, cholecystectomy, midepigastric, trocars, hemoclips, trocarNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

The description details a surgical procedure, specifically a laparoscopic cholecystectomy. While surgery is inherently a high-stakes situation due to potential complications and risks involved with any surgical intervention (such as injury to surrounding organs, infection, bleeding, or anesthesia-related issues), this procedure is described as having been completed successfully with the patient tolerating it well and in stable condition afterward. Therefore, while it is not an emergency or highly critical situation, the nature of surgery elevates its stakes considerably compared to non-surgical contexts.


Medical Specialty: Pain Management
Sample Name: Botox Injection - Trigger Point

PROCEDURE PERFORMED: , Trigger point injections with Botox.,PREPROCEDURE DIAGNOSES:,1. Cervical spondylosis without myelopathy.,2. Myofascial pain syndrome.,3. Cervical dystonia.,4. Status post C5-6 anterior cervical fusion.,5. Multilevel degenerative disc disease.,6. Cervicogenic migraines.,7. Hypertension.,8. Hypothyroidism.,POSTPROCEDURE DIAGNOSES:,1. Cervical spondylosis without myelopathy.,2. Myofascial pain syndrome.,3. Cervical dystonia.,4. Status post C5-6 anterior cervical fusion.,5. Multilevel degenerative disc disease.,6. Cervicogenic migraines.,7. Hypertension.,8. Hypothyroidism.,COMPLICATIONS: , None.,The risks, benefits, complications, and alternatives to the procedure were discussed in detail and informed written consent was obtained.,INDICATIONS:, The patient is here today after establishing care at my new office.  She is a long-term patient of mine at the Pain Management Clinic and has requested transference because of insurance reasons.  Today, she is here for not only establishment of care, but continued management of her many neck-related complaints.  Among these are spasms and ongoing pain for which she receives long-acting opioids.  She states that she is in fact doing quite well since her cervical fusion.  She is requesting that we decrease her medications from 480 mg to 240 mg to 360 mg of morphine per day in the form of Avinza.  She also is quite pleased with her other medication regimen which has been greatly simplified over the past year.,Other treatment modalities that have been helpful have included cervical epidural steroid injections.  The patient is requesting that we schedule this as well, as the relief provided by that lasted anywhere from four to six months.  I agree that because of intermittent radicular symptoms that this may be helpful particularly in light of her recent surgery.  She does complain of hand tingling and numbness, although she is not dropping objects or having difficulties with coordination.  I believe that in addition, the steroid injections may help expedite her desire to decrease her reliance on medications which have been oversedating as well as racked with other side effects.,DETAILS OF PROCEDURE: , Alcohol prep and sterile technique were used. A total of 6 cc of preservative-free 1% lidocaine was used and injected into eight different sites using a 25-gauge, 1-1/2-inch needle at the trapezius muscles bilaterally as well as the levator scapulae, the splenius capitis, and the semispinalis musculature.  The procedure was well tolerated.,TREATMENT PLAN:,1. The patient is tentatively scheduled for a cervical epidural steroid injection on March 14, 2005.,2. We will begin a weaning schedule for the patient's Avinza by decreasing in 60 mg intervals.  The patient will have a target of 120 mg p.o. b.i.d., and then be reassessed.  This is expected to occur after her cervical epidural steroid injection.
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DESCRIPTION: Trigger point injections with Botox.

Trigger point injections with Botox.

The situation involves a medical procedure (Botox injection for pain management) which typically carries risk of complications and affects ongoing pain treatment and medication management. However, the procedure is commonly performed and the patient has a history with the managing physician. The patient's care plan includes reducing opioid dependency, which is a significant medical decision impacting her ongoing treatment. The presence of multiple pre-existing conditions does add complexity, but there were no complications reported during the procedure and the patient has been managing well post-surgery. The risks are inherent in the medical context but not life-threatening given the information provided.


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

Medical Specialty: Pain Management
Sample Name: Epidural Steroid Injection

PRE-OP DIAGNOSES:,  Low back pain - 724.2, Herniated disc - 722.10, Lumbosacral Facet, arthropathy - 724.4.,POST-OP DIAGNOSES: , Low back pain - 724.2, Herniated disc - 722.10, Lumbosacral Facet, arthropathy - 724.4.,INTERVAL HISTORY:,  Plans, risks and options were reviewed with the patient in detail.  The patient understands and agrees to proceed.,ANESTHESIA: , General Anesthesia,PROCEDURE PERFORMED:,  Epidural steroid injection, epidurogram, fluroscopy.,PROCEDURE:,  After informed consent, the patient was taken to the procedure room and placed in the prone position.  EKG, blood pressure and pulse oximetry were monitored and remained stable throughout the procedure.  The area was prepped and draped in the usual sterile fashion.  Local anesthetic was infiltrated at the appropriate level.  Fluoroscopic guidance was used to place a #20-gauge Tuohy epidural needle gently into the epidural space at L4-L5 using a paramedian approach.  No blood or CSF was obtained on aspiration.,RADIOLOGY: , Injection of 3 cc of OMNIPAQUE showed spread of the dye into the epidural space on AP and Lateral imaging.  The Needle was injected with Depo-Medrol 80 mg with Bupivacaine 1/16th , 8 cc total vol.  Patient tolerated procedure well and was transferred to recovery room.  Patient was discharged home with escort.  Discharge instructions were given.,POST-OP PLAN:,  I will see the patient back in my office in two weeks.  Continue p.r.n. medications as needed.
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DESCRIPTION: Epidural steroid injection, epidurogram, fluroscopy - Low back pain, herniated disc, lumbosacral Facet, arthropathy.

pain management, back pain, herniated disc, lumbosacral facet, epidural needle, lumbosacral facet arthropathy, epidural steroid injection, facet arthropathy, epidural space, injection, epidurogram, fluroscopy, herniated, lumbosacral, steroid, arthropathy, epidural,

This situation describes a medical procedure involving an epidural steroid injection for managing low back pain due to conditions like a herniated disc and facet arthropathy. While it is a standard procedure in pain management and not life-threatening, it does involve risks such as infection, bleeding, or adverse reactions to the medication. However, these risks are relatively low, and the patient was under general anesthesia with proper monitoring, indicating a controlled environment. The procedure is critical to the patient's pain management but not extraordinarily high-stakes in a broader medical context.


Medical Specialty: Pediatrics - Neonatal
Sample Name: URI & Eustachian Congestion

HISTORY OF PRESENT ILLNESS: , Patient is a 14-year-old white female who presents with her mother complaining of a four-day history of cold symptoms consisting of nasal congestion and left ear pain.  She has had a dry cough and a fever as high as 100, but this has not been since the first day.  She denies any vomiting or diarrhea.  She did try some Tylenol Cough and Cold followed by Tylenol Cough and Cold Severe, but she does not think that this has helped.,FAMILY HISTORY: , The patient's younger sister has recently had respiratory infection complicated by pneumonia and otitis media.,REVIEW OF SYSTEMS:,  The patient does note some pressure in her sinuses.  She denies any skin rash.,SOCIAL HISTORY:,  Patient lives with her mother, who is here with her.,Nursing notes were reviewed with which I agree.,PHYSICAL EXAMINATION,VITAL SIGNS:  Temp is 38.1, pulse is elevated at 101, other vital signs are all within normal limits.  Room air oximetry is 100%.,GENERAL:  Patient is a healthy-appearing, white female, adolescent who is sitting on the stretcher, and appears only mildly ill.,HEENT:  Head is normocephalic, atraumatic.  Pharynx shows no erythema, tonsillar edema, or exudate.  Both TMs are easily visualized and are clear with good light reflex and no erythema.  Sinuses do show some mild tenderness to percussion.,NECK:  No meningismus or enlarged anterior/posterior cervical lymph nodes.,HEART:  Regular rate and rhythm without murmurs, rubs, or gallops.,LUNGS:  Clear without rales, rhonchi, or wheezes.,SKIN:  No rash.,ASSESSMENT:,  Viral upper respiratory infection (URI) with sinus and eustachian congestion.,PLAN:,  I did educate the patient about her problem and urged her to switch to Advil Cold & Sinus for the next three to five days for better control of her sinus and eustachian discomfort.  I did urge her to use Afrin nasal spray for the next three to five days to further decongest her sinuses.  If she is unimproved in five days, follow up with her PCP for re-exam.
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DESCRIPTION: Viral upper respiratory infection (URI) with sinus and eustachian congestion.  Patient is a 14-year-old white female who presents with her mother complaining of a four-day history of cold symptoms consisting of nasal congestion and left ear pain.

pediatrics - neonatal, upper respiratory infection, eustachian congestion, erythema, uri, nasal, cough, eustachian, respiratory, sinus, congestion, infection, tonsillar

The situation involves a 14-year-old patient with symptoms of a viral upper respiratory infection and eustachian congestion. While the symptoms can be uncomfortable and require monitoring to ensure they don't develop into more serious infections like pneumonia or otitis media, the current assessment and management plan are typical and low-risk. The patient is not in immediate danger, and clear instructions for managing symptoms and follow-up care are provided. Since the suggested treatment involves over-the-counter medication and monitoring, this situation is standard in a pediatric setting.


Medical Specialty: Psychiatry / Psychology
Sample Name: Psychiatric Consult - 2

HISTORY OF PRESENT ILLNESS:,  This is a 41-year-old registered nurse (R.N.).  She was admitted following an overdose of citalopram and warfarin.  The patient has had increasing depression and has been under stress as a result of dissolution of her second marriage.  She notes starting in January, her husband of five years seemed to be quite withdrawn.  It turned out, he was having an affair with one of her best friends and he subsequently moved in with this woman.  The patient is distressed, as over the five years of their marriage, she has gotten herself into considerable debt supporting him and trying to find a career that would work for him.  They had moved to ABCD where he had recently been employed as a restaurant manager.  She also moved her mother and son out there and is feeling understandably upset that he was being dishonest and deceitful with her.  She has history of seasonal affective disorder, winter depressions, characterized by increased sleep, increased irritability, impatience, and fatigue.  Some suggestion on her part that her father may have had some mild bipolar disorder and including the patient has a cyclical and recurrent mood disorder.  In January, she went on citalopram.  She reports since that time, she has lost 40 pounds of weight, has trouble sleeping at night, thinks perhaps her mood got worse on the citalopram, which is possible, though it is also possible that the progressive nature of getting divorce than financial problems has contributed to her worsening mood.,PAST AND DEVELOPMENTAL HISTORY: , She was born in XYZ.  She describes the family as being somewhat dysfunctional.  Father was a truckdriver.  She is an only child.  She reports that she had a history of anorexia and bulimia as a teenager.  In her 20s, she served six years in Naval Reserve.  She was previously married for four years.  She described that as an abusive relationship.  She had a history of being in counseling with ABC, but does not think this therapist, who is now by her estimate 80 years old, is still in practice.,PHYSICAL EXAMINATION:  ,GENERAL:  This is an alert and cooperative woman.,VITAL SIGNS:  Temperature 98.1, pulse 60, respirations 18, blood pressure 95/54, oxygen saturation 95%, and weight is 132.,PSYCHIATRIC:  She makes good eye contact.  Speech is normal in rate, volume, grammar, and vocabulary.  There is no thought disorder.  She denies being suicidal.  Her affect is appropriate for material being discussed.  She has a sense of future, wants to get back to work, has plans to return to counseling.  She appeared to have normal orientation, concentration, memory, and judgment.,Medical history is notable for factor V Leiden deficiency, history of pulmonary embolus, restless legs syndrome.  She has been off her Mirapex.  I did encourage her to go back on the Mirapex, which would likely lead to some improvement in mood by facilitating better sleep.,The patient at this time can contract for safety.  She has made plans for outpatient counseling this Saturday and we will get a referral to a psychiatrist for which she is agreeable to following up with.,LABORATORY DATA: , INR, which is still 8.8.  In 1998, she had a normal MRI.  Electrolytes, BUN, creatinine, and CBC were all normal.,DIAGNOSES:  ,1.  Seasonal depressive disorder.,2.  Restless legs syndrome.,3.  Overdose of citalopram and warfarin.,RECOMMENDATIONS: , The patient reports she has been feeling better since discontinuing antidepressants.  I, therefore, recommend she stay off antidepressants at present.  If needed, she can take Prozac, which has been effective for her in the past and she plans to see a psychiatrist for consultation.  She does give a fairly good history of seasonal depression and given that her mood has improved in the past with Prozac, this will be an appropriate agent to try as needed in the future, but given the situational nature of the depression, she primarily appears to need counseling.,Please feel free to contact me at digital pager if there is additional information I can provide.
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DESCRIPTION: She was admitted following an overdose of citalopram and warfarin.  The patient has had increasing depression and has been under stress as a result of dissolution of her second marriage.

psychiatry / psychology, citalopram, depressive disorder, overdose, warfarin, restless legs syndrome, disorder, mood

The situation described involves a patient who attempted an overdose with citalopram and warfarin, which is a serious and potentially life-threatening act. This indicates a high-stakes situation due to the risk of self-harm, compounded by her current psychological stressors, including a recent marriage dissolution and financial problems. The patient, however, is alert, cooperative, has a sense of future, denies being suicidal, and has made proactive plans for counseling, which somewhat mitigates the immediate high-risk factor. Nonetheless, the fact that she was admitted for an overdose reflects an underlying high-stakes mental health concern.


Medical Specialty: Surgery
Sample Name: Cleft Repair

PREOPERATIVE DIAGNOSES: , Bilateral cleft lip and bilateral cleft of the palate.,POSTOPERATIVE DIAGNOSES: , Bilateral cleft lip and bilateral cleft of the palate.,PROCEDURE PERFORMED: , Repair of bilateral cleft of the palate with vomer flaps.,ESTIMATED BLOOD LOSS: , 40 mL.,COMPLICATIONS: , None.,ANESTHESIA: , General endotracheal anesthesia.,CONDITION OF THE PATIENT AT THE END OF THE PROCEDURE:,  Stable, extubated, and transferred to the recovery room in stable condition.,INDICATIONS FOR PROCEDURE:  ,The patient is a 10-month-old baby with a history of a bilateral cleft of the lip and palate.  The patient has undergone cleft lip repair, and she is here today for her cleft palate operation.  We have discussed with the mother the nature of the procedure, risks, and benefits; the risks included but not limited to the risk of bleeding, infection, dehiscence, scarring, the need for future revision surgeries.  We will proceed with surgery.,DETAILS OF THE PROCEDURE:,  The patient was taken into the operating room, placed in the supine position, and general anesthetic was administered.  A prophylactic dose of antibiotics was given.  The patient proceeded to have bilateral PE tube placement by Dr. X, from Ear, Nose, and Throat Surgery.  After he was done with his procedure, the head of the bed was turned 90 degrees.  The patient was positioned with a shoulder roll and doughnut.  A Dingman retractor was placed.  The operative area was infiltrated with lidocaine with epinephrine 1:200,000, a total of 3 mL, and then, I proceeded with the prepping and draping.  The patient was prepped and draped.  I proceeded to do the palate repair.  The nature of the palate repair was done in the same way on the both sides.  I will describe one side.  The other side was done exactly in the same manner.  The 2 hemiuvulas are placed, holding from a single hook and infiltrated with lidocaine with epinephrine 1:200,000, triangle in the nasal mucosa was previously marked.  This triangle of nasal mucosa was removed and excised.  This was done on both uvulas.  Then, an incision was done at the level of the palatal cleft at the junction of the nasal and oral mucosa.  A 1-mm cuff of oral mucosa was used to be able to approximate the nasal mucosa better.  Once the incision was done up to the level of the hard palate, the muscle was dissected off the surrounding tissue, 2 mm from the nasal and the oral mucosa.  Then, I proceeded to place an incision at the alveolopalatal junction with the help of 15-blade.  The incision starts at the maxillary tuberosity posteriorly and comes anteriorly at the alveolopalatal junction through the full thickness of mucoperiosteal flap.  Then the flap was lifted up with the help of a freer, and then the remaining of the incision medially was completed.  Hemostasis was achieved with help of electrocautery and Surgicel.  The mucoperiosteal flap was retracted posteriorly with the help of a freer elevator.  The greater auricular foramen was exposed, and the pedicle skeletonized to allow medial retraction of the mucoperiosteal flap.  Then an osteotomy was done at the level of the greater auricular foramen to allow mobilization of the pedicle medially as well as a small incision was done in the periosteum around the pedicle.  The pedicle carefully dissected to allow better mobilization of the mucoperiosteal flap medially.  This procedure was done on both sides in the same manner, and then __________ dissection was done including dissection of the hard palate from the nasal mucosa, it was evident that the nasal mucosa would not reach medially to be placed together.  At this point, the decision was made to proceed with vomer flaps.  The flaps are __________ infiltrated the vomer with the help of lidocaine with epinephrine after an incision in the manner of an open book.  The incision was done with a 15C blade.  The vomer flaps were dissected, and the mucosa was moved laterally to approximate to the nasal mucosa of the hard palate.  This was approximated on both sides with 5-0 chromic running and interrupted stitches, and I proceeded to the remaining of the posterior aspect of the nasal mucosa with a 5-0 chromic and a 4-0 chromic.  Then 2 stitches of 4-0 Vicryl were applied to the soft palate in the Delaire manner through the full thickness of the mucosa and muscle on one side, on the other side, and then coming back on the mucosa to evert the edges of the soft palate.  The remaining part of the soft palate was placed together with 4-0 Vicryl and 4-0 chromic interrupted stitches.  The throat pack was removed.  The palate was cleaned.  The Dingman retractor was removed, and a single stitch after infiltration of lidocaine without epinephrine at the level of the midline of the tongue was applied with 2-0 silk to the dorsal aspect of the tongue and attached to the right cheek with a piece of Tegaderm.  The patient tolerated the procedure without complications.  BSS is applied to the eye after removing the Tegaderm.  I was present and participated in all aspects of the procedure.  The sponge, needle, and instrument count were completed at the end of the procedure.  The patient tolerated the procedure without complications and was transferred to the recovery room in a stable condition.
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DESCRIPTION: Repair of bilateral cleft of the palate with vomer flaps.

surgery, bilateral cleft, cleft lip, oral mucosa, hard palate, soft palate, vomer flaps, mucoperiosteal flap, nasal mucosa, flaps, cleft, mucosa, palate, mucoperiosteal, bilateral, nasal,

The surgery being described is a cleft palate repair in a 10-month-old baby, which is indeed a significant medical procedure. The stakes are relatively high because it involves surgery under general anesthesia in an infant, where there are known risks such as bleeding, infection, and potential need for future surgeries. However, the procedure went smoothly without complications, and the patient was stable afterwards. This reduces the immediate stakes of the situation but doesn't undermine the inherent risks of such surgeries and the importance of successful outcomes for the child's development and quality of life.


Medical Specialty: Neurology
Sample Name: Dandy-Walker Malformation

CC:, Seizure D/O,HX:, 29 y/o male with cerebral palsy, non-shunted hydrocephalus, spastic quadriplegia, mental retardation, bilateral sensory neural hearing loss, severe neurogenic scoliosis and multiple contractures of the 4 extremities, neurogenic bowel and bladder incontinence, and a history of seizures.,He was seen for evaluation of seizures which first began at age 27 years, two years before presentation. His typical episodes consist of facial twitching (side not specified), unresponsive pupils, and moaning. The episodes last approximately 1-2 minutes in duration and are followed by post-ictal fatigue. He was placed on DPH, but there was no record of an EEG prior to presentation. He had had no seizure events in over 1 year prior to presentation while on DPH 100mg--O--200mg. He also complained of headaches for the past 10 years.,BIRTH HX:, Spontaneous Vaginal delivery at 36weeks gestation to a G2P1 mother. Birth weight 7#10oz. No instrumentation required. Labor = 11hours. "Light gas anesthesia" given. Apgars unknown. Mother reportedly had the "flu" in the 7th or 8th month of gestation.,Patient discharged 5 days post-partum.,Development: spoke first words between 1 and 2 years of age. Rolled side to side at age 2, but did not walk. Fed self with hands at age 2 years. Never toilet trained.,PMH: ,1)Hydrocephalus manifested by macrocephaly by age 2-3 months. Head circumference 50.5cm at 4 months of age (wide sutures and bulging fontanels). Underwent ventriculogram, age 4 months, which illustrated massive enlargement of the lateral ventricles and normal sized aqueduct and 4th ventricle. The cortex of the cerebral hemisphere was less than 1cm. in thickness; especially in the occipital regions where only a thin rim of tissue was left. Neurosurgical intervention was not attempted and the patient deemed inoperable at the time. By 31 months of age the patients head circumference was 68cm, at which point the head size arrested. Other problems mentioned above.,SHX: ,institutionalized at age 18 years.,FHX: ,unremarkable.,EXAM:, Vitals unknown.,MS: awake with occasional use of intelligible but inappropriately used words.,CN: Rightward beating nystagmus increase on leftward gaze. Right gaze preference. Corneal responses were intact bilaterally. Fundoscopic exam not noted.,Motor: spastic quadriparesis. moves RUE more than other extremities.,Sensory: withdrew to PP in 4 extremities.,Coord: ND,Station: ND,Gait: ND, wheel chair bound.,Reflexes: RUE 2+, LUE 3+, RLE 4+ with sustained cross adductor clonus in the right quadriceps. LLE 3+.,Other: Macrocephaly (measurement not given). Scoliosis. Rest of general exam unremarkable except for numerous abdominal scars.,COURSE:, EEG 8/26/92: Abnormal with diffuse slowing and depressed background (left worse than right) and poorly formed background activity at 5-7hz. Right posterior sharp transients, and rhythmic delta-theta bursts from the right temporal region. The findings are consistent with diffuse cerebral dysfunction and underlying seizure tendency of multifocal origin.
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DESCRIPTION: CT Brain - unshunted hydrocephalus, Dandy-Walker Malformation.

neurology, seizure, dandy-walker malformation, eeg, macrocephaly, bilateral sensory neural hearing loss, hydrocephalus, hythmic delta-theta bursts, mental retardation, neurogenic bowel and bladder incontinence, severe neurogenic scoliosis, spastic quadriplegia, unshunted hydrocephalus, dandy walker malformation, dandy walker, head circumference, presentation, gestation, headaches, incontinence,

The case involves a patient with a complex medical history, including Dandy-Walker Malformation, cerebral palsy, and a range of neurological and physical impairments. The patient also presents with seizure disorder that started relatively late and exhibits a multifocal seizure tendency. Given the severe impairments and the complexity of managing such a case, the stakes are high because any change in treatment, even minor, could significantly affect the patient's quality of life and neurological function. The absence of prior EEGs and the reported headaches further complicate the clinical evaluation. Additionally, the case requires careful medication management to prevent seizure recurrence and manage symptoms effectively.


Medical Specialty: Nephrology
Sample Name: Renal Transplant - Cadaveric

HISTORY OF PRESENT ILLNESS:  ,The patient is a 50-year-old African American female with past medical history significant for hypertension and endstage renal disease, on hemodialysis secondary to endstage renal disease, last hemodialysis was on June 22, 2007.  The patient presents with no complaints for cadaveric renal transplant.  After appropriate cross match and workup of HLA typing of both recipient and cadaveric kidneys, the patient was deemed appropriate for operative intervention and transplantation of kidney.,PREOPERATIVE DIAGNOSIS:,  Endstage renal disease.,POSTOPERATIVE DIAGNOSIS: , Endstage renal disease.,PROCEDURE:,  Cadaveric renal transplant to right pelvis.,ESTIMATED BLOOD LOSS: , 400 mL.,FLUIDS:  ,One liter of normal saline and one liter of 5% of albumin.,ANESTHESIA:  ,General endotracheal.,SPECIMEN:  ,None.,DRAIN: , None.,COMPLICATIONS: , None.,The patient tolerated the procedure without any complication.,PROCEDURE IN DETAIL:  ,The patient was brought to the operating room, prepped and draped in sterile fashion.  After adequate anesthesia was achieved, a curvilinear incision was made in the right pelvic fossa approximately 9 cm in length extending from the 1.5 cm medial of the ASIS down to the suprapubic space.  After this was taken down with a #10 blade, electrocautery was used to take down tissue down to the layer of the subcutaneous fat.  Camper's and Scarpa's were dissected with electrocautery.  Hemostasis was achieved throughout the tissue plains with electrocautery.  The external oblique aponeurosis was identified with musculature and was entered with electrocautery.  Then hemostats were entered in and dissection continued down with electrocautery down through the external internal obliques and the transversalis fascia.  Additionally, the rectus sheath was entered in a linear fashion.  After these planes were entered using electrocautery, the retroperitoneum was dissected free from the transversalis fascia using blunt dissection.  After the peritoneum and peritoneal structures were moved medially and superiorly by blunt dissection, the dissection continued down bluntly throughout the tissue planes removing some alveolar tissue over the right iliac artery.  Upon entering through the transversalis fascia, the epigastric vessels were identified and doubly ligated and tied with #0 silk ties.  After the ligation of the epigastric vessels, the peritoneum was bluntly dissected and all peritoneal structures were bluntly dissected to a superior and medial plane.  This was done without any complication and without entering the peritoneum grossly.  The round ligament was identified and doubly ligated at this time with #0 silk ties as well.  The dissection continued down now to layer of the alveolar tissue covering the right iliac artery.  This alveolar tissue was cleared using blunt dissection as well as electrocautery.  After the external iliac artery was identified, it was cleared circumferentially all the way around and noted to have good flow and had good arterial texture.  The right iliac vein was then identified, and this was cleared again using electrocautery and blunt dissection.  After the right iliac vein was identified and cleared off all the alveolar tissue, it was circumferentially cleared as well.  An additional perforating branch was noted at the inferior pole of the right iliac vein.  This was tied with a #0 silk tie and secured.  Hemostasis was achieved at this time and the tie had adequate control.  The dissection continued down and identified all other vital structures in this area.  Careful preservation of all vital structures was carried out throughout the dissection.  At this time, Satinsky clamp was placed over the right iliac vein.  This was then opened using a #11 blade, approximately 1 cm in length.  The heparinized saline was placed and irrigated throughout the inside of the vein, and the kidney was pulled into the abdominal field still covered in its protective socking with the superior pole marked.  The renal vein was then elevated and identified in this area.  A 5-0 double-ended Prolene stitch was used to secure the renal vein, both superiorly and inferiorly, and after appropriately being secured with 5-0 Prolene, these were tied down and secured.  The renal vein was then anastomosed to the right iliac vein in a circumferential manner in a running fashion until secured at both superior and inferior poles.  The dissection then continued down and the iliac artery was then anastomosed to the renal artery at this time using a similar method with 5-0 Prolene securing both superior and inferior poles.  After such time the 5-0 Prolene was run around in a circumferential manner until secured in both superior and inferior poles once again.  After this was done and the artery was secured, the Satinsky clamp was removed and a bulldog placed over.  The flow was then opened on the arterial side and then opened on the venous side to allow for proper flow.  The bulldog was then placed back on the renal vein and allowed for the hyperperfusion of the kidney.  The kidney pinked up nicely and had a good appearance to it and had appearance of good blood flow.  At this time, all Satinsky clamps were removed and all bulldog clamps were removed.  The dissection then continued down to the layer of the bladder at which time the bladder was identified.  Appropriate area on the dome the bladder was identified for entry.  This was entered using electrocautery and approximately 1 cm length after appropriately sizing and incising of the ureter using the Metzenbaum scissors in a linear fashion.  Before this was done, #0 chromic catgut stitches were placed and secured laterally and inferiorly on the dome of the bladder to elevate the area of the bladder and then the bladder was entered using the electrocautery approximately 1 cm in length.  At this time, a renal stent was placed into the ureter and secured superiorly and the stent was then placed into the bladder and secured as well.  Subsequently, the superior and inferior pole stitches with 5-0 Prolene were used to secure the ureter to the bladder.  This was then run mucosa-to-mucosa in a circumferential manner until secured in both superior and inferior poles once again.  Good flow was noted from the ureter at the time of operation.  Additional Vicryl stitches were used to overlay the musculature in a seromuscular stitch over the dome of the bladder and over the ureter itself.  At this time, an Ethibond stitch was used to make an additional seromuscular closure and rolling of the bladder musculature over the dome and over the anastomosis once again.  This was inspected and noted for proper control.  Irrigation of the bladder revealed that the bladder was appropriately filled and there were no flows and no defects.  At this time, the anastomoses were all inspected, hemostasis was achieved and good closure of the anastomosis was noted at this time.  The kidney was then placed back into its new position in the right pelvic fossa, and the area was once again inspected for hemostasis which was achieved.  A 1-0 Prolene stitch was then used for mass closure of the external, internal, and transversalis fascias and musculature in a running fashion from superior to inferior.  This was secured and knots were dumped.  Subsequently, the area was then checked and inspected for hemostasis which was achieved with electrocautery, and the skin was closed with 4-0 running Monocryl.  The patient tolerated procedure well without evidence of complication, transferred to the Dunn ICU where he was noted to be stable.  Dr. A was present and scrubbed through the entire procedure.
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DESCRIPTION: Cadaveric renal transplant to right pelvis - endstage renal disease.

nephrology, endstage renal disease, ethibond, satinsky clamp, aponeurosis, cadaveric, cross match, curvilinear incision, hemodialysis, iliac vein, pelvic fossa, peritoneum, recipient, renal transplant, transplant, transversalis fascia, superior and inferior poles, endstage renal, renal disease, vein, electrocautery, bladder, renal, intervention,

A cadaveric renal transplant is a significant medical procedure that can have life-changing effects on the patient. Given the patient's history of endstage renal disease, dependence on hemodialysis, and the complexity of the surgery involved, the situation is inherently high-stakes. The successful transplantation can extend the patient's life and improve their quality of life, whereas complications could have serious consequences. The detailed description of the surgical process also emphasizes the critical nature of the procedure.