Medical Specialty: Orthopedic
Sample Name: Ligament Reconstruction & Meniscus Repair

PREOPERATIVE DIAGNOSES:,1.  Torn anterior cruciate ligament, right knee.,2.  Patellofemoral instability, right knee.,3.  Possible torn medial meniscus.,POSTOPERATIVE DIAGNOSES:,1.  Complete tear anterior cruciate ligament, right knee.,2.  Complex tear of the posterior horn lateral meniscus.,3.  Tear of posterior horn medial meniscus.,4.  Patellofemoral instability.,5.  Chondromalacia patella.,PROCEDURES PERFORMED:,1.  Diagnostic operative arthroscopy with repair and reconstruction of anterior cruciate ligament using autologous hamstring tendon, a 40 mm bioabsorbable femoral pin, and a 9 mm bioabsorbable tibial pin.,2.  Repair of lateral meniscus using two fast fixed meniscal repair sutures.,3.  Partial medial meniscectomy.,4.  Partial chondroplasty of patella.,5.  Lateral retinacular release.,6.  Open medial plication as well of the right knee.,ANESTHESIA:,  General.,COMPLICATIONS:,  None.,TOURNIQUET TIME:,  130 minutes at 325 mmHg.,INTRAOPERATIVE FINDINGS: , There was noted to be a grade-II chondromalacia patellofemoral joint.  The patella was noted to be situated laterally past the lateral femoral condyle.  There was a tear to the posterior horn of the medial meniscus within the white zone.  There was a complex tear involving a horizontal cleavage component to the posterior horn of the lateral meniscus as well in the entire meniscus.  There was a complete tear of the anterior cruciate ligament.  The posterior cruciate ligament appeared intact.  Preoperatively, she had a positive Lachman with a positive pivot shift test as well as increased patellofemoral instability.,HISTORY: , This is a 39-year-old female who has sustained a twisting injury to her knee while on trampoline in late August.  She was diagnosed per MRI.  An MRI confirmed the clinical diagnosis of anterior cruciate ligament tear.  She states she has had multiple episodes of instability to the patellofemoral joint throughout the years with multiple dislocations.  She elected to proceed with surgery to repair the anterior cruciate ligament as well as possibly plicate the medial retinaculum to help prevent further dislocations of the patellofemoral joint.  All risks and benefits of surgery were discussed with her at length.  She was in agreement with the treatment plan.,PROCEDURE:  ,On 09/11/03, she was taken to the operating room at ABCD General Hospital.  She was placed supine on the operating table.  General anesthetic was applied by the Anesthesiology Department.  Tourniquet was placed on the proximal thigh and it was then placed in a knee holder.  She was sterilely prepped and draped in the usual fashion.  An Esmarch was used to exsanguinate the lower extremity.  Tourniquet was inflated to 325 mmHg.  Longitudinal incision was made just medial to the tibial tubercle.  The subcutaneous tissue was carefully dissected.  Hemostasis was controlled with electrocautery.  The tendons of gracilis and semitendinosus were identified and isolated, and then stripped off the musculotendinous junction.  They were taken on the back table.  The soft tissue debris was removed from the tendons.  The ends of the tendons were sewn together using #5 Tycron whip type sutures.  The tendons were measured on back table and found to be 8 mm as the most adequate size, they were then placed under tension on the back table.  Stab incision was made in the inferolateral parapatellar region, through this camera was placed in the knee.  The knee was inflated with saline solution and operative pictures were obtained.  The above findings were noted.  A second port site was initiated in the inferomedial parapatellar region.  Through this, a probe was placed.  Tear in the posterior horn medial meniscus was identified.  It was resected using a meniscal resector.  It was then further contoured using arthroscopic shaver.  Attention was then taken to the lateral compartment.  A partial meniscectomy was performed using the resector and the shaver.  The posterior periphery of the lateral meniscus was also noticed to be unstable.  A repair was then performed using two fasting fixed meniscal repair sutures to help anchor the meniscus around the popliteus tendon.  There was noted to be excellent fixation.  The shaver was then taken into the intrachondral notch.  First a partial chondroplasty was performed on the patella to remove the loose articular debris as well as a partial synovectomy to the medial aspect of the patellar femoral joint.  Next, the remnant of the anterior cruciate ligament was removed using the arthroscopic shaver and arthroplasty was then performed on the medial aspect of the lateral femoral condyle.  Next, a tibial guide was placed through the anterior medial portal.  A ___ pin was then placed up through the anterior incision entering the tibial eminence just anterior to the posterior cruciate ligament.  This tibial tunnel was then drilled using 8 mm cannulated drill.  Next, an over-the-top guide was then placed at approximately the 11:30 position.  A ____ pin was then placed into the femur and 8 mm drill was then used to drill this femoral tunnel approximately 35 mm.  Next the U shape guide was placed through tibial tunnel into the femur.  A pin was then placed through the distal femur from lateral to medial, through the U-shaped guide a puller wire was then passed through the distal femur.  It was then pulled out through the tibial tunnel using the You-shaped guide.  The tendon was then placed around the wire.  The wire was pulled back up through the tibial into the femoral tunnel.  A 40 mm bioabsorbable pin was then placed through the femoral tunnel securing the hamstring tendons.  Attention was then pulled through the tibial tunnel.  The knee was cycled approximately 20 times.  A 9 mm bioabsorbable screw was then placed through the tibial tunnel fixating the distal aspect of the graft.  There was noted definite fixation of the graft.  There was no evidence of impingement either in full flexion or full extension.  The knee was copiously irrigated and it was then suctioned dry.  A longitudinal incision was made just medial to the patellofemoral joint.  Soft tissues were carefully dissected and the medial retinaculum was incised along with the incision.  Following this, a release of lateral retinaculum was performed using a knife to further release the patellofemoral joint and allow further medial plication.  The medial retinaculum was then plicated using #1 Ethibond sutures and then oversewn with #0 Vicryl suture.  The subcuticular tissues were reapproximated with #2-0 Vicryl simple interrupted sutures followed by a #4-0 PDS running subcuticular stitch.  She was placed in a DonJoy knee immobilizer.  The tourniquet was deflated.  It was noted the lower extremity was warm and pink with good capillary refill.  She was transferred to the recovery room in apparent stable and satisfactory condition.  Prognosis for this patient is guarded.  She will be full weightbearing on the lower extremity using the knee immobilizer locked in extension.  She may remove her dressing two to three days, however, follow back in the office in 10 to 14 days for suture removal.  She will require one to two more physical therapy to help regain motion and strength to the lower extremity.
---
DESCRIPTION: Diagnostic operative arthroscopy with repair and reconstruction of anterior cruciate ligament using autologous hamstring tendon, a 40 mm bioabsorbable femoral pin, and a 9 mm bioabsorbable tibial pin.  Repair of lateral meniscus using two fast fixed meniscal repair sutures.  Partial medial meniscectomy.  Partial chondroplasty of patella.  Lateral retinacular release.  Open medial plication as well of the right knee.

The described situation involves a complex knee surgery with several procedures performed, including ligament reconstruction, meniscus repair, and more. Despite the complexity, there were no intraoperative complications, and the patient was stable post-surgery. While recovery involves careful management and rehabilitation, these types of surgeries are routine in orthopedic practice. The detailed surgical description and guarded prognosis suggest it's a significant but managed medical situation without immediate life-threatening risks. Hence, it's important but not extremely high-stakes compared to emergencies.


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

Medical Specialty: Surgery
Sample Name: Flexible Cystoscopy - Atrophic Vaginitis

PREOPERATIVE DIAGNOSIS:,  Recurring bladder infections with frequency and urge incontinence, not helped with Detrol LA.,POSTOPERATIVE DIAGNOSIS: , Normal cystoscopy with atrophic vaginitis.,PROCEDURE PERFORMED: , Flexible cystoscopy.,FINDINGS:,  Atrophic vaginitis.,PROCEDURE:  ,The patient was brought in to the procedure suite, prepped and draped in the dorsal lithotomy position.  The patient then had flexible scope placed through the urethral meatus and into the bladder.  Bladder was systematically scanned noting no suspicious areas of erythema, tumor or foreign body.  Significant atrophic vaginitis is noted.,IMPRESSION: , Atrophic vaginitis with overactive bladder with urge incontinence.,PLAN: , The patient will try VESIcare 5 mg with Estrace and follow up in approximately 4 weeks.
---
DESCRIPTION: Recurring bladder infections with frequency and urge incontinence, not helped with Detrol LA.  Normal cystoscopy with atrophic vaginitis.

surgery, urge incontinence, frequency, overactive bladder, vesicare, flexible cystoscopy, bladder infections, atrophic vaginitis, incontinence, cystoscopy, vaginitis,

This medical case involves a diagnostic procedure to investigate urinary issues and diagnose atrophic vaginitis. While it is important for the patient's quality of life and comfort, the situation does not involve immediate or life-threatening conditions such as a cardiovascular emergency or cancer. Flexible cystoscopy is considered a routine procedure, and the immediate treatment plan involves medication adjustments and follow-up in a month, suggesting that the stakes, while medically significant, are not critical in nature.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Surgery
Sample Name: Cystopyelogram - 1

PREOPERATIVE DIAGNOSIS: , Gross hematuria.,POSTOPERATIVE DIAGNOSIS:  ,Gross hematuria.,OPERATIONS:  ,Cystopyelogram, clot evacuation, transurethral resection of the bladder tumor x2 on the dome and on the left wall of the bladder.,ANESTHESIA: , Spinal.,FINDINGS:  ,Significant amount of bladder clots measuring about 150 to 200 mL, two cupful of clots were removed.  There was papillary tumor on the left wall right at the bladder neck and one on the right dome near the bladder neck on the right side.  The right ureteral opening was difficult to visualize, the left one was normal.,BRIEF HISTORY: , The patient is a 78-year-old male with history of gross hematuria and recurrent UTIs.  The patient had hematuria.  Cystoscopy revealed atypical biopsy.  The patient came in again with gross hematuria.  The first biopsy was done about a month ago.  The patient was to come back and have repeat biopsies done, but before that came into the hospital with gross hematuria.  The options of watchful waiting, removal of the clots and biopsies were discussed.  Risk of anesthesia, bleeding, infection, pain, MI, DVT and PE were discussed.  Morbidity and mortality of the procedure were discussed.  Consent was obtained from the daughter-in-law who has the power of attorney in Florida.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the OR.  Anesthesia was applied.  The patient was placed in the dorsal lithotomy position.  The patient was prepped and draped in the usual sterile fashion.  The patient had been off of the Coumadin for about 4 days and INR had been reversed.  The patient has significant amount of clot upon entering the bladder.  There was a tight bladder neck contracture.  The prostate was not enlarged.  Using ACMI 24-French sheath, using Ellick irrigation about 2 cupful of clots were removed.  It took about half an hour to just remove the clots.  After removing the clots, using 24-French cutting loop resectoscope, tumor on the left upper wall near the dome or near the 2 o'clock position was resected.  This was lateral to the left ureteral opening.  The base was coagulated for hemostasis.  Same thing was done at 10 o'clock on the right side where there was some tumor that was visualized.  The back wall and the rest of the bladder appeared normal.  Using 8-French cone-tip catheter, left-sided pyelogram was normal.  The right-sided pyelogram was very difficult to obtain and there was some mucosal irritation from the clots.  The contrast did go up to what appeared to be the right ureteral opening, but the mucosa seemed to be very much irritated and it was very difficult to actually visualize the opening.  A little bit of contrast went out, but the force was not made just to avoid any secondary stricture formation.  The patient did have CT with contrast, which showed that the kidneys were normal.  At this time, a #24 three-way irrigation was started.  The patient was brought to Recovery room in stable condition.
---
DESCRIPTION: Cystopyelogram, clot evacuation, transurethral resection of the bladder tumor x2 on the dome and on the left wall of the bladder.

surgery, clot evacuation, transurethral resection, bladder tumor, bladder neck, gross hematuria, bladder, cystopyelogram, hematuria, clots,

The situation involves a significant surgical procedure on a 78-year-old male patient with gross hematuria and bladder tumors. Considering the patient's age, history of recurrent UTIs, and the risks associated with anesthesia and the surgical procedure (bleeding, infection, potential for myocardial infarction, deep vein thrombosis, and pulmonary embolism), this scenario is high-stakes. Surgery is inherently risky, particularly in older patients with multiple comorbidities, due to potential complications that could arise during or after the procedure. Additionally, the consent was obtained from a person with the power of attorney, indicating the patient's condition could be quite severe. Thus, the procedural and ethical considerations add to the high-stake nature of this medical situation.


Medical Specialty: Consult - History and Phy.
Sample Name: Recurrent Abscesses - Consult

REASON FOR CONSULTATION: , Recurrent abscesses in the thigh, as well as the pubic area for at least about 2 years.,HISTORY OF PRESENT ILLNESS:,  A 23-year-old female who is approximately 5 months' pregnant, who has had recurrent abscesses in the above-mentioned areas.  She would usually have pustular type of lesion that would eventually break and would be quite painful.  The drainage would be malodorous.  It would initially not be infected as far as she knows, but then could eventually become infected.  She stated that this first started after she had her first born about 2 years ago.  She had recurrences of these abscesses and had pain, actually hospitalized at Hospital approximately a year and a half ago for about 1-1/2 months.  She was treated with multiple courses of antibiotics.  She had biopsies done.  She was seen by Dr. X.  Reportedly, she had a HIV test done that was negative.  She had been seen by a dermatologist who said that she had a problem with her sweat glands.  She has been on multiple courses of antibiotics.  She never had any fevers.  She has pain, drainage, and reportedly there was some bleeding in the area of the perineum/vaginal area.,PAST MEDICAL HISTORY:,1.  History of recurrent abscesses in the perineum, upper medial thigh, and the vulva area for about 2 years.  Per her report, a dermatologist had told her that she had an overactive sweat gland, and I believe she probably has hidradenitis suppurativa.  Probably, she has had Staphylococcus infection associated with it as well.,2.  Reported history of asthma.,GYNECOLOGIC HISTORY: , G3, P1.  She is currently 5 months' pregnant.,ALLERGIES: , None.,MEDICATIONS: , Her medication had been Augmentin.,SOCIAL HISTORY: , She is followed by a gynecologist in Bartow.  She is not an alcohol or tobacco user.  She is not married.  She has a 2-year-old child.,FAMILY HISTORY:  ,Noncontributory.,REVIEW OF SYSTEMS: , The patient has been complaining of diarrhea about 5 or 6 times a day for several weeks now.,PHYSICAL EXAMINATION,GENERAL:
---
DESCRIPTION: Recurrent abscesses in the thigh, as well as the pubic area for at least about 2 years.   In the past, Accutane has been used.

The situation involves a 23-year-old pregnant woman experiencing recurrent abscesses, indicative of hidradenitis suppurativa. This condition, along with possible Staphylococcus infections, requires careful management due to her pregnancy and its potential impact on her health and that of the unborn child. Although not immediately life-threatening, the complexity, chronic pain, and potential for infection elevate it to a moderate high-stakes level.


Medical Specialty: Neurology
Sample Name: Neuropsychological Evaluation

REASON FOR REFERRAL: , Ms. A is a 60-year-old African-American female with 12 years of education who was referred for neuropsychological evaluation by Dr. X after she demonstrated mild cognitive deficits on a neuropsychological screening evaluation during a followup appointment with him for stroke in July.  A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning.,RELEVANT BACKGROUND INFORMATION:,  Historical information was obtained from a review of available medical records and clinical interview with Ms. A.  A summary of pertinent information is presented below.  Please refer to the patient's medical chart for a more complete history.,HISTORY OF PRESENTING PROBLEM:,  Ms. A presented to the ABC Hospital emergency department on 07/26/2009 reporting that after she had woken up that morning she noticed numbness and weakness in her left hand, slurred speech, and left facial droop.  Neurological evaluation with Dr. X confirmed left hemiparesis.  Brain CT showed no evidence of intracranial hemorrhage or mass effect and that she received TPA and had moderate improvement in left-sided weakness.  These symptoms were thought to be due to a right middle cerebral artery stroke.  She was transferred to the ICU for monitoring.  Ultrasound of the carotids showed 20% to 30% stenosis of the right ICA and 0% to 19% stenosis of the left ICA.  On 07/29/2009, she was admitted for acute inpatient rehabilitation for the treatment of residual functional deficits of her acute ischemic right MCA/CVA.  At discharge on 08/06/2009, she was mainly on supervision for all ADLs and walking with a rolling walker, but tolerating increased ambulation with a cane.  She was discharged home with recommendations for outpatient physical therapy.  She returned to the Sinai ER on 08/2009/2009 due to reported left arm pain, numbness, and weakness, which lasted 10 to 15 minutes and she reported that it felt "just like the stroke."  Brain CT on 08/2009/2009 was read as showing "mild chronic microvascular ischemic change of deep white matter," but no acute or significant interval change compared to her previous scan.  Neurological examination with Dr. Y was within normal limits, but she was admitted for a more extensive workup.  Due to left arm pain an ultrasound was completed on her left upper extremity, but it did not show deep vein thrombosis.,Followup CT on 08/10/2009 showed no significant interval change.  MRI could not be completed due to the patient's weight.  She was discharged on 08/11/2009 in stable condition after it was determined that this event was not neurological in origin; however, note that Ms. A referred to this as a second stroke.,Ms. A presented for a followup outpatient neurological evaluation with Dr. X on 09/22/2009, at which time a brief neuropsychological screening was also conducted.  She demonstrated significant impairments in confrontation naming, abstract verbal reasoning, and visual and verbal memory and thus a more comprehensive evaluation was suggested due to her intent to return to her full-time work duty.  During the current interview, Ms. A reported that she noticed mild memory problems including some difficultly remembering conversations, events, and at times forgetting to take her medications.  She also reported mild difficulty finding words in conversation, solving novel problems and tasks (e.g. difficulty learning to use her camcorder), but overall denied significant cognitive deficits in attention, concentration, language or other areas of cognitive functioning.  When asked about her return to work, she said that she was still on light duty due to limited physical activity because of residual left leg weakness.  She reported that no one had indicated to her that she appeared less capable of performing her job duties, but said that she was also receiving fewer files to process and enter data into the computer at the Social Security Agency that she works at.  Note also that she had some difficulty explaining exactly what her job involved.  She also reported having problems falling asleep at work and that she is working full-time although on light duty.,OTHER MEDICAL HISTORY:  ,As mentioned, Ms. A continues to have some residual left leg weakness and continues to use a rolling walker for ambulation, but she reported that her motor functioning had improved significantly.  She was diagnosed with sleep apnea approximately two years ago and was recently counseled by Dr. X on the need to use her CPAP because she indicated she never used it at night.  She reported that since her appointment with Dr. X, she has been using it "every other night."  When asked about daytime fatigue, Ms. A initially denied that she was having any difficulties, but repeatedly indicated that she was falling asleep at work and thought that it was due to looking at a computer screen.  She reported at times "snoring" and forgetting where she is at and said that a supervisor offered to give her coffee at one point.  She receives approximately two to five hours of sleep per night.  Other current untreated risk factors include obesity and hypercholesterolemia.  Her medical history is also significant for hypertension, asthma, abdominal adenocarcinoma status post hysterectomy with bilateral salpingo-oophorectomy, colonic benign polyps status post resection, benign lesions of the breast status post lumpectomy, and deep vein thrombosis in the left lower extremity status post six months of anticoagulation (which she had discontinued just prior to her stroke).,CURRENT MEDICATIONS: , Aspirin 81 mg daily, Colace 100 mg b.i.d., Lipitor 80 mg daily, and albuterol MDI p.r.n.,SUBSTANCE USE:,  Ms. A denied drinking alcohol or using illicit drugs.  She used to smoke a pack of cigarettes per day, but quit five to six years ago.,FAMILY MEDICAL HISTORY: , Ms. A had difficulty providing information on familial medical history.  She reported that her mother died three to four years ago from lung cancer.  Her father has gout and blood clots.  Siblings have reportedly been treated for asthma and GI tumors.  She was unsure of familial history of other conditions such as hypertension, high cholesterol, stroke, etc.,SOCIAL HISTORY: , Ms. A completed high school degree.  She reported that she primarily obtained B's and C's in school.  She received some tutoring for algebra in middle school, but denied ever having been held back a grade failing any classes or having any problems with attention or hyperactivity.,She currently works for the Social Security Administration in data processing.  As mentioned, she has returned to full-time work, but continues to perform only light duties due to her physical condition.  She is now living on her own.  She has never driven.  She reported that she continues to perform ADLs independently such as cooking and cleaning.  She lost her husband in 2005 and has three adult daughters.  She previously reported some concerns that her children wanted her to move into assisted living, but she did not discuss that during this current evaluation.  She also reported number of other family members who had recently passed away.  She has returned to activities she enjoys such as quire, knitting, and cooking and plans to go on a cruise to the Bahamas at the end of October.,PSYCHIATRIC HISTORY: , Ms. A did not report a history of psychological or psychiatric treatment.  She reported that her current mood was good, but did describe some anxiety and nervousness about various issues such as her return to work, her upcoming trip, and other events.  She reported that this only "comes and goes.",TASKS ADMINISTERED:,Clinical Interview,Adult History Questionnaire,Wechsler Test of Adult Reading (WTAR),Mini Mental Status Exam (MMSE),Cognistat Neurobehavioral Cognitive Status Examination,Repeatable Battery for the Assessment of Neuropsychological Status (RBANS; Form XX),Mattis Dementia Rating Scale, 2nd Edition (DRS-2),Neuropsychological Assessment Battery (NAB),Wechsler Adult Intelligence Scale, Third Edition (WAIS-III),Wechsler Adult Intelligence Scale, Fourth Edition (WAIS-IV),Wechsler Abbreviated Scale of Intelligence (WASI),Test of Variables of Attention (TOVA),Auditory Consonant Trigrams (ACT),Paced Auditory Serial Addition Test (PASAT),Ruff 2 & 7 Selective Attention Test,Symbol Digit Modalities Test (SDMT),Multilingual Aphasia Examination, Second Edition (MAE-II),  Token Test,  Sentence Repetition,  Visual Naming,  Controlled Oral Word Association,  Spelling Test,  Aural Comprehension,  Reading Comprehension,Boston Naming Test, Second Edition (BNT-2),Animal Naming Test
---
DESCRIPTION: Patient demonstrated mild cognitive deficits on a neuropsychological screening evaluation during a followup appointment for stroke.

The situation involves a neuropsychological evaluation for a 60-year-old woman with a history of stroke and cognitive deficits seeking to return to full-time work. This case has significant implications for the patient's quality of life, independence, and ability to perform her job. Her medical history includes serious conditions such as stroke, hypertension, obesity, and sleep apnea, all of which can contribute to cognitive deficits. The evaluation results will influence diagnostic decisions and treatment plans, directly affecting her healthcare and daily functioning. While this is important for the patient's wellbeing, it doesn't involve immediate life-or-death decisions or urgent medical interventions, placing it at a moderate level of stakes.


Medical Specialty: Orthopedic
Sample Name: Achilles Lengthening

PREOPERATIVE DIAGNOSIS: , Idiopathic toe walker.,POSTOPERATIVE DIAGNOSIS: , Idiopathic toe walker.,PROCEDURE: , Bilateral open Achilles lengthening with placement of short leg walking cast.,ANESTHESIA: , Surgery performed under general anesthesia.  A total of 10 mL of 0.5% Marcaine local anesthetic was used.,COMPLICATIONS:  ,No intraoperative complications.,DRAINS: , None.,SPECIMENS: , None.,TOURNIQUET TIME:  ,On the left side was 30 minutes, on the right was 21 minutes.,HISTORY AND PHYSICAL:,  The patient is a 10-year-old boy who has been a toe walker since he started ambulating at about a year.  The patient had some mild hamstring tightness with his popliteal angle of approximately 20 degrees bilaterally.  He does not walk with a crouched gait but does toe walk.  Given his tightness, surgery versus observation was recommended to the family.  Family however wanted to correct his toe walking.  Surgery was then discussed.  Risks of surgery include risks of anesthesia, infection, bleeding, changes in sensation and motion of the extremities, failure to resolve toe walking, possible stiffness, cast, and cast problems.  All questions were answered and parents agreed to above surgical plan.,PROCEDURE IN DETAIL: , The patient was taken to the operating room and placed supine on the operating table  General anesthesia was then administered.  The patient received Ancef preoperatively.  The patient was then subsequently placed prone with all bony prominences padded.  Two bilateral nonsterile tourniquets were placed on each thigh.  Both extremities were then prepped and draped in a standard surgical fashion.  We turned our attention first towards the left side.  A planned incision of 1 cm medial to the Achilles tendon was marked on the skin.  The extremity was wrapped in Esmarch prior to inflation of tourniquet to 250 mmHg.  Incision was then made and carried down through subcutaneous fat down to the tendon sheath.  Achilles tendon was identified and Z-lengthening was done with the medial distal half cut.  Once Z-lengthening was completed proximally, the length of the Achilles tendon was then checked.  This was trimmed to obtain an end-on-end repair with 0 Ethibond suture.  This was also oversewn.  Wound was then irrigated.  Achilles tendon sheath was reapproximated using 2-0 Vicryl as well as the subcutaneous fat.  The skin was closed using 4-0 Monocryl.  Once the wound was cleaned and dried and dressed with Steri-Strips and Xeroform, the area was injected with 0.5% Marcaine.  It was then dressed with 4 x 4 and Webril.  Tourniquet was released at 30 minutes.  The same procedure was repeated on the right side with tourniquet time of 21 minutes.  While the patient was still prone, two short-leg walking casts were then placed.  The patient tolerated the procedure well and was subsequently flipped supine on to hospital gurney and taken to PACU in stable condition.,POSTOPERATIVE PLAN:  ,The patient will be discharged on the day of surgery.  He may weightbear as tolerated in his cast, which he will have for about 4 to 6 weeks.  He is to follow up in approximately 10 days for recheck as well as prescription for intended AFOs, which he will need up to 6 months.  The patient may or may not need physical therapy while his Achilles lengthenings are healing.  The patient is not to participate in any PE for at least 6 months.  The patient is given Tylenol No. 3 for pain.
---
DESCRIPTION: Bilateral open Achilles lengthening with placement of short leg walking cast.

orthopedic, toe walker, achilles lengthening, idiopathic toe walker, short leg walking, subcutaneous fat, tendon sheath, leg walking, achilles tendon, toe, tourniquet, tendon, intraoperative,

The situation involves a surgical procedure, which inherently carries certain risks and complications, making it higher stakes than non-surgical scenarios. However, the procedure described is a routine orthopedic surgery with no intraoperative complications reported. The stakes are moderate because it affects the patient's mobility and recovery involves a period of non-participation in physical activities. The procedure still has significant importance for the patient's quality of life, and successful recovery can lead to improved mobility, but it does not carry life-threatening consequences. Therefore, the stakes in terms of impact on health and life are moderate.


Medical Specialty: Radiology
Sample Name: Bilateral Mammogram

EXAM:,  Mammographic screening FFDM,HISTORY: , 40-year-old female who is on oral contraceptive pills.  She has no present symptomatic complaints.  No prior history of breast surgery nor family history of breast CA.,TECHNIQUE: , Standard CC and MLO views of the breasts.,COMPARISON: , This is the patient's baseline study.,FINDINGS: , The breasts are composed of moderately to significantly dense fibroglandular tissue.  The overlying skin is unremarkable.,There are a tiny cluster of calcifications in the right breast, near the central position associated with 11:30 on a clock.,There are benign-appearing calcifications in both breasts as well as unremarkable axillary lymph nodes.,There are no spiculated masses or architectural distortion.,IMPRESSION:,  Tiny cluster of calcifications at the 11:30 position of the right breast.  Recommend additional views; spot magnification in the MLO and CC views of the right breast.,BIRADS Classification 0 - Incomplete,MAMMOGRAPHY INFORMATION:,1.  A certain percentage of cancers, probably 10% to 15%, will not be identified by mammography.,2.  Lack of radiographic evidence of malignancy should not delay a biopsy if a clinically suspicious mass is present.,3.  These images were obtained with FDA-approved digital mammography equipment, and iCAD Second Look Software Version 7.2 was utilized.
---
DESCRIPTION: Bilateral Mammogram, (abnormal) additional views requested

radiology, ffdm, mammographic screening, tiny cluster of calcifications, bilateral mammogram, additional views, bilateral, mammogram, cluster, breasts, calcifications, mammography,

This situation involves a routine screening mammogram for a patient with no high-risk history for breast cancer. The findings indicate a need for additional imaging, which is not uncommon in radiology, especially when addressing dense breast tissue and calcifications. The BIRADS classification of 0 means more information is needed, not necessarily indicating an immediate high risk. While follow-up imaging is important for appropriate diagnosis, the lack of immediate clinical symptoms or high-risk family history suggests this is a low-stakes situation compared to others in medical practice.


Medical Specialty: Neurosurgery
Sample Name: Craniotomy - Biparietal

PREOPERATIVE DIAGNOSES: , Multiple metastatic lesions to the brain, a subtentorial lesion on the left, greater than 3 cm, and an infratentorial lesion on the right, greater than 3 cm.,POSTOPERATIVE DIAGNOSES: , Multiple metastatic lesions to the brain, a subtentorial lesion on the left, greater than 3 cm, and an infratentorial lesion on the right, greater than 3 cm.,TITLE OF THE OPERATION:,1.  Biparietal craniotomy and excision of left parietooccipital metastasis from breast cancer.,2.  Insertion of left lateral ventriculostomy under Stealth stereotactic guidance.,3.  Right suboccipital craniectomy and excision of tumor.,4.  Microtechniques for all the above.,5.  Stealth stereotactic guidance for all of the above and intraoperative ultrasound.,INDICATIONS: , The patient is a 48-year-old woman with a diagnosis of breast cancer made five years ago.  A year ago, she was diagnosed with cranial metastases and underwent whole brain radiation.  She recently has deteriorated such that she came to my office, unable to ambulate in a wheelchair.  Metastatic workup does reveal multiple bone metastases, but no spinal cord compression.  She had a consult with Radiation-Oncology that decided they could radiate her metastases less than 3 cm with stereotactic radiosurgery, but the lesions greater than 3 cm needed to be removed.  Consequently, this operation is performed.,PROCEDURE IN DETAIL: , The patient underwent a planning MRI scan with Stealth protocol.  She was brought to the operating room with fiducial still on her scalp.  General endotracheal anesthesia was obtained.  She was placed on the Mayfield head holder and rolled into the prone position.  She was well padded, secured, and so forth.  The neck was flexed so as to expose the right suboccipital region as well as the left and right parietooccipital regions.  The posterior aspect of the calvarium was shaved and prepared in the usual manner with Betadine soak scrub followed by Betadine paint.  This was done only, of course, after fiducial were registered in planning and an excellent accuracy was obtained with the Stealth system.  Sterile drapes were applied and the accuracy of the system was confirmed.  A biparietal incision was performed.  A linear incision was chosen so as to increase her chances of successful wound healing and that she is status post whole brain radiation.  A biparietal craniotomy was carried out, carrying about 1 cm over toward the right side and about 4 cm over to the left side as guided by the Stealth stereotactic system.  The dura was opened and reflected back to the midline.  An inner hemispheric approach was used to reach the very large metastatic tumor.  This was very delicate removing the tumor and the co-surgeons switched off to spare one another during the more delicate parts of the operation to remove the tumor.  The tumor was wrapped around and included the choroidal vessels.  At least one choroidal vessel was sacrificed in order to obtain a gross total excision of the tumor on the parietal occipital region.  Bleeding was quite vigorous in some of the arteries and finally, however, was completely controlled.  Complete removal of the tumor was confirmed by intraoperative ultrasound.,Once the tumor had been removed and meticulous hemostasis was obtained, this wound was left opened and attention was turned to the right suboccipital area.  A linear incision was made just lateral to the greater occipital nerve.  Sharp dissection was carried down in the subcutaneous tissues and Bovie electrocautery was used to reach the skull.  A burr hole was placed down low using a craniotome.  A craniotomy was turned and then enlarged as a craniectomy to at least 4 cm in diameter.  It was carried caudally to the floor of the posterior fossa and rostrally to the transverse sinus.  Stealth and ultrasound were used to localize the very large tumor that was within the horizontal hemisphere of the cerebellum.  The ventriculostomy had been placed on the left side with the craniotomy and removal of the tumor, and this was draining CSF relieving pressure in the posterior fossa.  Upon opening the craniotomy in the parietal occipital region, the brain was noted to be extremely tight, thus necessitating placement of the ventriculostomy.,At the posterior fossa, a corticectomy was accomplished and the tumor was countered directly.  The tumor, as the one above, was removed, both piecemeal and with intraoperative Cavitron Ultrasonic Aspirator.  A gross total excision of this tumor was obtained as well.,I then explored underneath the cerebellum in hopes of finding another metastasis in the CP angle; however, this was just over the lower cranial nerves, and rather than risk paralysis of pharyngeal muscles and voice as well as possibly hearing loss, this lesion was left alone and to be radiated and that it is less than 3 cm in diameter.,Meticulous hemostasis was obtained for this wound as well.,The posterior fossa wound was then closed in layers.  The dura was closed with interrupted and running mattress of 4-0 Nurolon.  The dura was watertight, and it was covered with blue glue.  Gelfoam was placed over the dural closure.  Then, the muscle and fascia were closed in individual layers using #0 Ethibond.  Subcutaneous was closed with interrupted inverted 2-0 and 0 Vicryl, and the skin was closed with running locking 3-0 Nylon.,For the cranial incision, the ventriculostomy was brought out through a separate stab wound.  The bone flap was brought on to the field.  The dura was closed with running and interrupted 4-0 Nurolon.  At the beginning of the case, dural tack-ups had been made and these were still in place.  The sinuses, both the transverse sinus and sagittal sinus, were covered with thrombin-soaked Gelfoam to take care of any small bleeding areas in the sinuses.,Once the dura was closed, the bone flap was returned to the wound and held in place with the Lorenz microplates.  The wound was then closed in layers.  The galea was closed with multiple sutures of interrupted 2-0 Vicryl.  The skin was closed with a running locking 3-0 Nylon.,Estimated blood loss for the case was more than 1 L.  The patient received 2 units of packed red cells during the case as well as more than 1 L of Hespan and almost 3 L of crystalloid.,Nevertheless, her vitals remained stable throughout the case, and we hopefully helped her survival and her long-term neurologic status for this really nice lady.
---
DESCRIPTION: Biparietal craniotomy, insertion of left lateral ventriculostomy, right suboccipital craniectomy and excision of tumor.

neurosurgery, metastatic lesion, biparietal, mayfield head holder, microtechniques, stealth, craniotomy, excision, fiducial, infratentorial, parietooccipital, stereotactic, suboccipital, subtentorial, ventriculostomy, lesions to the brain, removal of the tumor, parietal occipital region, running locking nylon, biparietal craniotomy, posterior fossa, tumor, brain, dura, lesions,

This situation involves a complex neurosurgical operation to manage brain metastases from breast cancer. The patient has deteriorated significantly and the surgery aims to improve survival and neurological function. The stakes are high due to the complex nature of the surgery, significant blood loss, involvement of critical brain areas, and the patient's critical condition. Such situations are inherently high-stakes due to the potential for serious complications or impacts on quality of life.


Medical Specialty: Surgery
Sample Name: Umbilical Hernia Repair

PREOPERATIVE DIAGNOSIS: , Umbilical hernia.,POSTOPERATIVE DIAGNOSIS: , Umbilical hernia.,PROCEDURE PERFORMED: , Repair of umbilical hernia.,ANESTHESIA: , General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Minimal.,PROCEDURE IN DETAIL:  ,The patient was prepped and draped in the sterile fashion.  An infraumbilical incision was formed and taken down to the fascia.  The umbilical hernia carefully reduced back into the cavity, and the fascia was closed with interrupted vertical mattress sutures to approximate the fascia, and then the wounds were infiltrated with 0.25% Marcaine.  The skin was reattached to the fascia with 2-0 Vicryls.  The skin was approximated with 2-0 Vicryl subcutaneous and then 4-0 Monocryl subcuticular stitches, dressed with Steri-Strips and 4 x 4's.  Patient was extubated and taken to the recovery area in stable condition.
---
DESCRIPTION: Umbilical hernia repair template.  The umbilical hernia carefully reduced back into the cavity, and the fascia was closed with interrupted vertical mattress sutures to approximate the fascia.

surgery, marcaine, steri-strips, mattress sutures, umbilical hernia, repair, umbilical, hernia,

Umbilical hernia repair is a common surgical procedure with a good prognosis and low complication rates when performed by a skilled surgeon. The details provided indicate that the procedure went smoothly with no complications and minimal blood loss. General anesthesia was used, which is routine for such surgeries. While surgery always carries some risks, this particular procedure and its outcome seem to be on the lower end of the risk spectrum. Therefore, the stakes are not extremely high compared to more complex or emergency surgeries.


Medical Specialty: Radiology
Sample Name: CT Abdomen & Pelvis - 6

REASON FOR EXAM: , Right-sided abdominal pain with nausea and fever.,TECHNIQUE: , Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue-300.,CT ABDOMEN:  ,The liver, spleen, pancreas, gallbladder, adrenal glands, and kidney are unremarkable.,CT PELVIS: , Within the right lower quadrant, the appendix measures 16 mm and there are adjacent inflammatory changes with fluid in the right lower quadrant.  Findings are compatible with acute appendicitis.,The large and small bowels are normal in course and caliber without obstruction.  The urinary bladder is normal.  The uterus appears unremarkable.  Mild free fluid is seen in the lower pelvis.,No destructive osseous lesions are seen.  The visualized lung bases are clear.,IMPRESSION: , Acute appendicitis.
---
DESCRIPTION: Right-sided abdominal pain with nausea and fever.  CT abdomen with contrast and CT pelvis with contrast.  Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue-300.

radiology, adrenal glands, appendicitis, gallbladder, kidney, liver, pancreas, spleen, acute appendicitis, ct pelvis, ct abdomen, abdominal, contrast, fluid, abdomen, inflammatory, pelvis, ct

The situation involves diagnosing acute appendicitis through a CT scan, which can require prompt surgical intervention to prevent complications like rupture or peritonitis. This is a common and treatable condition, but timely action is crucial to avoid severe complications.


Medical Specialty: Consult - History and Phy.
Sample Name: First Pap smear.

CHIEF COMPLAINT:,  The patient comes for her first Pap smear, complaining of irregular periods.,HISTORY OF PRESENT ILLNESS:,  The patient wishes to discuss considering something to help with her menstrual cramping and irregular periods.  She notes that her periods are out of weck.  She says that she has cramping and pain before her period starts.  Sometimes, she is off her period for two weeks and then she bleeds for two whole weeks.  She usually has her periods lasting seven days, usually comes on the 19th of each month and now it seems to have changed.  The cramping is worse.  She said her flow has increased.  She has to change her pad every half to one hour and uses a super tampon sometimes.  She usually has four days of hard flow and then she might have 10 days where she will have to wear a mini pad.  She also notes that her headaches have been worsening a little bit.  She has had quite a bit of stress.  She had a headache on Wednesday again after having had one on the weekend.  She said she usually only has an occasional headache and that is not too bad but now she has developed what she would consider to be a migraine and she has not had serious headaches like this and it seems to be worsening and coming a little bit more regularly, and she has not figure out what to do to get rid of them.  She avoids caffeine.  She only eats chocolate when she is near her period and she usually drinks one can of cola a day.,MEDICATIONS: , None.,ALLERGIES:,  None.,SOCIAL HISTORY:,  She is a nonsmoker.  She is not sexually active.,PAST MEDICAL HISTORY:,  She has had no surgery or chronic illnesses.,FAMILY HISTORY:,  Mother has hypertension, depression.  Father has had renal cysts and sometimes some stomach problems.  Both of her parents have problems with their knees.,REVIEW OF SYSTEMS:,  Patient denies headache or trauma.  No blurred or double vision.  Hearing is fine, no tinnitus or infection.  Infrequent sore throat, no hoarseness or cough.,HEENT:  See HPI.,Neck:  No stiffness, pain or swelling.,Respiratory:  No shortness of breath, cough or hemoptysis.  She is a nonsmoker.,Cardiovascular:  No chest pain, ankle edema, palpitations or hypertension.,GI:  No nausea, vomiting, diarrhea, constipation, melena or jaundice.,GU:  No dysuria, frequency, urgency or stress incontinence.,Locomotor:  No weakness, joint pain, tremor or swelling.,GYN:  See HPI.,Integumentary:  Patient performs self-breast examinations and denies any breast masses or nipple discharge.  No recent skin or hair changes.,Neuropsychiatric:  Denies depression, anxiety, tearfulness or suicidal thought.,PHYSICAL EXAMINATION:,VITALS:  Height 64.5 inches.  Weight:  162 pounds.  Blood pressure 104/72.  Pulse:  72.  Respirations:  16.  LMP:  08/21/04.  Age:  19.,HEENT:  Head is normocephalic.  Eyes:  EOMs intact.  PERRLA.  Conjunctiva clear.  Fundi:  Discs flat, cups normal.  No AV nicking, hemorrhage or exudate.  Ears:  TMs intact.  Mouth:  No lesion.  Throat:  No inflammation.,Neck:  Full range of motion.  No lymphadenopathy or thyromegaly.,Chest:  Clear to auscultation and percussion.,Heart:  Normal sinus rhythm, no murmur.,Integumentary:  Breasts are without masses, tenderness, nipple retraction or discharge.  Reviewed self-breast examination.  No axillary nodes are palpable.,Abdomen:  Soft.  Liver, spleen, and kidneys are not palpable.  No masses felt, nontender.  Femoral pulses strong and equal.,Back:  No CVA or spinal tenderness.  No deformity noted.,Pelvic:  BUS negative.  Vaginal mucosa pink, scanty discharge.  Cervix without lesion.  Pap was taken.  Uterus normal size.  Adnexa:  No masses.  She does have some pain on palpation of the uterus.,Rectal:  Good sphincter tone.  No masses.  Stool is guaiac negative.,Extremities:  No edema.  Pulses strong and equal.  Reflexes are intact.,Rectal:  No mass.,ASSESSMENT:,  Menorrhagia, pelvic pain, dysmenorrhea, and irregular periods.,PLAN:,  We will evaluate with a CBC, urinalysis and culture, and TSH.  The patient has what she describes as migraine headaches of a new onset.  Because of the pelvic pain, dysmenorrhea, and menorrhagia, we will also evaluate with a pelvic sonogram.  We will evaluate with a CT scan of the brain with and without contrast.  We will try Anaprox DS one every 12 hours for the headache.  At this point, she could also use that for menstrual cramping.  Prescription written for 20 tablets.  If her lab findings, sonographic findings, and CT of the brain are normal, we would consider trying birth control pills to regulate her periods and reduce the cramping and excessive flow.  The lab x-ray and urinalysis results will be reported to her as soon as they are available.
---
DESCRIPTION: First Pap smear, complaining of irregular periods.  - Menorrhagia, pelvic pain, dysmenorrhea, and irregular periods.

The situation described involves a medical consultation for a 19-year-old patient experiencing menorrhagia, pelvic pain, dysmenorrhea, irregular periods, and new onset migraines. These symptoms, while potentially indicative of underlying health conditions, are not immediately life-threatening. The medical team is planning a comprehensive evaluation including blood tests, a pelvic sonogram, and a CT scan. These steps are proactive and appropriate for addressing the patient's symptoms, which suggests that the situation is not extremely urgent but requires careful investigation and management. Thus, it is not considered high-stakes in a life-critical sense but does require attention to ensure appropriate care and intervention.


Medical Specialty: Surgery
Sample Name: Flex Sig

MEDICATIONS:,  None.,DESCRIPTION OF THE PROCEDURE:,  After informed consent was obtained, the patient was placed in the left lateral decubitus position and the Olympus video colonoscope was inserted through the anus and advanced in retrograde fashion for a distance of *** cm to the proximal descending colon and then slowly withdrawn.  The mucosa appeared normal.  Retroflex examination of the rectum was normal.
---
DESCRIPTION: Flexible Sigmoidoscopy.

Flexible Sigmoidoscopy.

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

This scenario describes the performance of a flexible sigmoidoscopy procedure, which is a routine medical diagnostic procedure used to examine the lower part of the colon. From the description, the procedure went normally with findings indicating normal mucosa and rectum. While medical procedures can carry inherent risks, flexible sigmoidoscopies generally have low risk and are routine when performed by trained professionals. The situation does not suggest complications, urgency, or critical conditions that raise the stakes considerably.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Cardiolite Treadmill Stress Test

CARDIOLITE TREADMILL EXERCISE STRESS TEST,CLINICAL DATA:,  This is a 72-year-old female with history of diabetes mellitus, hypertension, and right bundle branch block.,PROCEDURE:,  The patient was exercised on the treadmill to maximum tolerance achieving after 5 minutes a peak heart rate of 137 beats per minute with a workload of 2.3 METS.  There was a normal blood pressure response.  The patient did not complain of any symptoms during the test and other than the right bundle branch block that was present at rest, no other significant electrographic abnormalities were observed.,Myocardial perfusion imaging was performed at rest following the injection of 10 mCi Tc-99 Cardiolite.  At peak pharmacological effect, the patient was injected with 30 mCi Tc-99 Cardiolite.,Gating poststress tomographic imaging was performed 30 minutes after the stress.,FINDINGS:,1.  The overall quality of the study is fair.,2.  The left ventricular cavity appears to be normal on the rest and stress studies.,3.  SPECT images demonstrate fairly homogeneous tracer distribution throughout the myocardium with no overt evidences of fixed and/or reperfusion defect.,4.  The left ventricular ejection fraction was normal and estimated to be 78%.,IMPRESSION: , Myocardial perfusion imaging is normal.  Result of this test suggests low probability for significant coronary artery disease.
---
DESCRIPTION: Cardiolite treadmill exercise stress test.  The patient was exercised on the treadmill to maximum tolerance achieving after 5 minutes a peak heart rate of 137 beats per minute with a workload of 2.3 METS.

cardiovascular / pulmonary, peak heart rate, bundle branch block, perfusion imaging, stress test, mci, ventricular, cardiolite, treadmill,

The scenario presented involves a routine diagnostic procedure, the Cardiolite treadmill exercise stress test, on a 72-year-old female patient with a history of diabetes, hypertension, and right bundle branch block. The findings from the test were normal, indicating a low probability of significant coronary artery disease. The situation has been successfully managed without any complications, and there are no immediate risks to the patient's health. Routine diagnostic evaluations typically are not considered high-stakes unless they reveal critical or life-threatening conditions, which is not the case here.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Exercise Stress Test - 4

INDICATION: , Chest pain.,DESCRIPTION OF PROCEDURE: , After informed consent was obtained from the patient, the patient was brought to the cardiology procedure room where he was hooked up to continuous hemodynamic monitoring.  The patient's baseline heart rate was 85 beats per minute and blood pressure was 124/90.  The patient was started on a Bruce protocol where he exercised for 11 minutes and 42 seconds achieving 12.8 METs.  The patient's maximum blood pressure during this stress part was 148/80 and the patient achieved heart rate of 152 with no EKG changes, no chest pain.,FINDINGS:,1.  Normal hemodynamic response to exercise.,2.  No EKG changes suggestive of ischemia.,3.  No chest pain during the stress test.,4.  Achieved optimum METs for the exercise done and this is a normal exercise treadmill stress test.
---
DESCRIPTION: Chest pain.  Achieved optimum METs for the exercise done and this is a normal exercise treadmill stress test.

cardiovascular / pulmonary, treadmill stress test, heart rate, blood pressure, stress test, treadmill, hemodynamic, ekg, chest,

The situation involves interpreting the results of an Exercise Stress Test conducted on a patient with a history of chest pain. The test results were normal, indicating a normal hemodynamic response, no EKG changes suggestive of ischemia, no chest pain during the test, and achievement of the optimum METs. While evaluating cardiovascular health can be crucial, the complete absence of concerning findings in this specific test suggests a non-urgent scenario for the patient at this time. Therefore, the stakes are relatively low in confirming a normal test result.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: 2-D Echocardiogram - 1

2-D M-MODE: , ,1.  Left atrial enlargement with left atrial diameter of 4.7 cm.,2.  Normal size right and left ventricle.,3.  Normal LV systolic function with left ventricular ejection fraction of 51%.,4.  Normal LV diastolic function.,5.  No pericardial effusion.,6.  Normal morphology of aortic valve, mitral valve, tricuspid valve, and pulmonary valve.,7.  PA systolic pressure is 36 mmHg.,DOPPLER: , ,1.  Mild mitral and tricuspid regurgitation.,2.  Trace aortic and pulmonary regurgitation.
---
DESCRIPTION: 2-D M-Mode. Doppler.

2-D M-Mode. Doppler.

cardiovascular / pulmonary, 2-d m-mode, doppler, aortic valve, atrial enlargement, diastolic function, ejection fraction, mitral, mitral valve, pericardial effusion, pulmonary valve, regurgitation, systolic function, tricuspid, tricuspid valve, normal lv

The echocardiogram results show some abnormalities such as left atrial enlargement and mild mitral and tricuspid regurgitation. However, the left ventricular ejection fraction is within a reasonable range, and most other measurements and observations are normal, indicating that the heart is functioning relatively well. While any issue with heart function warrants monitoring and follow-up, the findings do not suggest an immediate risk of critical complications. Thus, while it is important to address and manage these conditions, it is not an extremely high-stakes situation.


Medical Specialty: Orthopedic
Sample Name: Pain Management Progress Note

DIAGNOSES:,1.  Cervical dystonia.,2.  Post cervical laminectomy pain syndrome.,Ms. XYZ states that the pain has now shifted to the left side.  She has noticed a marked improvement on the right side, which was subject to a botulinum toxin injection about two weeks ago.  She did not have any side effects on the Botox injection and she feels that her activities of daily living are increased, but she is still on the oxycodone and methadone.  The patient's husband confirms the fact that she is doing a lot better, that she is more active, but there are still issues yet regarding anxiety, depression, and frustration regarding the pain in her neck.,PHYSICAL EXAMINATION:,  The patient is appropriate.  She is well dressed and oriented x3.  She still smells of some cigarette smoke.  Examination of the neck shows excellent reduction in muscle spasm on the right paraspinals, trapezius and splenius capitis muscles.  There are no trigger points felt and her range of motion of the neck is still somewhat guarded, but much improved.  On the left side, however, there is significant muscle spasm with tight bands involving the multifidus muscle with trigger point activity and a lot of tenderness and guarding.  This extends down into the trapezius muscle, but the splenius capitis seems to be not involved.,TREATMENT PLAN:,  After a long discussion with the patient and the husband, we have decided to go ahead and do botulinum toxin injection into the left multifidus/trapezius muscles.  A total of 400 units of Botox is anticipated.  The procedure is being scheduled.  The patient's medications are refilled.  She will continue to see Dr. Berry and continue her therapy with Mary Hotchkinson in Victoria.
---
DESCRIPTION: Pain management sample progress note.

Pain management sample progress note.

orthopedic, progress note, management, muscle

The situation involves a patient with cervical dystonia and post-surgical pain management issues, which are being treated successfully with botulinum toxin injections. The stakes include managing chronic pain and preventing potential negative impacts on the patient’s quality of life due to pain, depression, and anxiety. However, the patient is seeing improvement, and the plan to continue treatment appears well-structured with medical oversight. The stakes are significant but managed within the scope of ongoing patient care and treatment, indicating a medium level of urgency rather than critical or life-threatening concerns at this time.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Transesophageal Echocardiogram

EXAM: , Transesophageal echocardiogram and direct current cardioversion.,REASON FOR EXAM:  ,1.  Atrial fibrillation with rapid ventricular rate.,2.  Shortness of breath.,PROCEDURE: , After informed consent was obtained, the patient was then sedated using a total of 4 mg of Versed and 50 mcg of fentanyl.  Following this, transesophageal probe was placed in the esophagus.  Transesophageal views of the heart were then obtained.,FINDINGS:,1.  Left ventricle is of normal size.  Overall LV systolic function is preserved.  Estimated ejection fraction is 60% to 65%.  No wall motion abnormalities are noted.,2.  Left atrium is dilated.,3.  Left atrial appendage is free of clots.,4.  Right atrium is of normal size.,5.  Right ventricle is of normal size.,6.  Mitral valve shows evidence of mild MAC.,7.  Aortic valve is sclerotic without significant restriction of leaflet motion.,8.  Tricuspid valve appears normal.,9.  Pulmonic valve appears normal.,10.  Pacer wires are noted in the right atrium and in the right ventricle.,11.  Doppler interrogation of moderate mitral regurgitation is present.,12.  Mild-to-moderate AI is seen.,13.  No significant TR is noted.,14.  No significant TI is noted.,15.  No pericardial disease seen.,IMPRESSION:,1.  Preserved left ventricular systolic function.,2.  Dilated left atrium.,3.  Moderate mitral regurgitation.,4.  Aortic valve sclerosis with mild-to-moderate aortic insufficiency.,5.  Left atrial appendage is free of clots.,Following these, direct current cardioversion was performed.  Three biphasic shock waves of 150 and two of 200 joules were then applied to the patient's chest in anteroposterior direction without success in conversion to sinus rhythm.  The patient remained in atrial fibrillation.,PLAN: , Plan will be to continue medical therapy.  We will consider using beta-blocker, calcium channel blockers for better ventricular rate control.
---
DESCRIPTION: Transesophageal echocardiogram and direct current cardioversion.

The situation involves a transesophageal echocardiogram and attempted cardioversion for a patient with atrial fibrillation, which is a significant cardiovascular condition that requires careful monitoring and treatment. While the immediate procedure did not result in a conversion to sinus rhythm, the patient's situation is under control with a treatment plan in place to manage the arrhythmia and related symptoms. The stakes are moderate because, although atrial fibrillation poses a risk of complications such as stroke, this encounter seems to be a routine assessment and initial management rather than a critical emergency. Hence, it is important but not extremely high-stakes.


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

Medical Specialty: Discharge Summary
Sample Name: Discharge Summary - Cerebral Palsy

DISCHARGE DIAGNOSES:,1.  Bilateral lower extremity cellulitis secondary to bilateral tinea pedis.,2.  Prostatic hypertrophy with bladder outlet obstruction.,3.  Cerebral palsy.,DISCHARGE INSTRUCTIONS: , The patient would be discharged on his usual Valium 10-20 mg at bedtime for spasticity, Flomax 0.4 mg daily, cefazolin 500 mg q.i.d., and Lotrimin cream between toes b.i.d. for an additional two weeks.  He will be followed in the office.,HISTORY OF PRESENT ILLNESS:,  This is a pleasant 62-year-old male with cerebral palsy.  The patient was recently admitted to Hospital with lower extremity cellulitis.  This resolved, however, recurred in both legs.  Examination at the time of this admission demonstrated peeling of the skin and excoriation between all of his toes on both feet consistent with tinea pedis.,PAST MEDICAL/FAMILY/SOCIAL HISTORY:,  As per the admission record.,REVIEW OF SYSTEMS: , As per the admission record.,PHYSICAL EXAMINATION:  ,As per the admission record.,LABORATORY STUDIES: , At the time of admission, his white blood cell count was 8200 with a normal differential, hemoglobin 13.6, hematocrit 40.6 with normal indices, and platelet count was 250,000.  Comprehensive metabolic profile was unremarkable, except for a nonfasting blood sugar of 137, lactic acid was 0.8.  Urine demonstrated 4-9 red blood cells per high-powered field with 2+ bacteria.  Blood culture and wound cultures were unremarkable.  Chest x-ray was unremarkable.,HOSPITAL COURSE: , The patient was admitted to the General Medical floor and treated with intravenous ceftriaxone and topical Lotrimin.  On this regimen, his lower extremity edema and erythema resolved quite rapidly.,Because of urinary frequency, a bladder scan was done suggesting about 600 cc of residual urine.  A Foley catheter was inserted and was productive of approximately 500 cc of urine.  The patient was prescribed Flomax 0.4 mg daily.  24 hours later, the Foley catheter was removed and a bladder scan demonstrated 60 cc of residual urine after approximately eight hours.,At the time of this dictation, the patient was ambulating minimally, however, not sufficiently to resume independent living.
---
DESCRIPTION: a pleasant 62-year-old male with cerebral palsy

discharge summary, bilateral lower extremity cellulitis, cerebral palsy, ambulating, bilateral tinea pedis, lower extremity cellulitis, cerebral, palsy, discharge,

The discharge summary indicates a stable medical condition, with the patient being treated for bilateral lower extremity cellulitis and having ongoing conditions such as cerebral palsy and prostatic hypertrophy. The conditions have non-critical management plans involving medications and follow-up. The patient is being discharged with instructions and medications rather than requiring immediate or intensive intervention, which generally doesn't classify this as a high-stakes situation. While the patient's mobility is limited, this does not immediately endanger life or require urgent action, as conditions are being managed and the patient is instructed to follow-up.


Medical Specialty: Gastroenterology
Sample Name: EGD & Colonoscopy

PREOPERATIVE DIAGNOSIS: , Blood loss anemia.,POSTOPERATIVE DIAGNOSES:,1.  Normal colon with no evidence of bleeding.,2.  Hiatal hernia.,3.  Fundal gastritis with polyps.,4.  Antral mass.,ANESTHESIA: , Conscious sedation with Demerol and Versed.,SPECIMEN:  ,Antrum and fundal polyps.,HISTORY: , The patient is a 66-year-old African-American female who presented to ABCD Hospital with mental status changes.  She has been anemic as well with no gross evidence of blood loss.  She has had a decreased appetite with weight loss greater than 20 lb over the past few months.  After discussion with the patient and her daughter, she was scheduled for EGD and colonoscopy for evaluation.,PROCEDURE: , After informed consent was obtained, the patient was brought to the endoscopy suite.  She was placed in the left lateral position and was given IV Demerol and Versed for sedation.  When adequate level of sedation was achieved, a digital rectal exam was performed, which demonstrated no masses and no hemorrhoids.  The colonoscope was inserted into the rectum and air was insufflated.  The scope was coursed through the rectum and sigmoid colon, descending colon, transverse colon, ascending colon to the level of the cecum.  There were no polyps, masses, diverticuli, or areas of inflammation.  The scope was then slowly withdrawn carefully examining all walls.  Air was aspirated.  Once in the rectum, the scope was retroflexed.  There was no evidence of perianal disease.  No source of the anemia was identified.,Attention was then taken for performing an EGD.  The gastroscope was inserted into the hypopharynx and was entered into the hypopharynx.  The esophagus was easily intubated and traversed.  There were no abnormalities of the esophagus.  The stomach was entered and was insufflated.  The scope was coursed along the greater curvature towards the antrum.  Adjacent to the pylorus, towards the anterior surface, was a mass like lesion with a central _______.  It was not clear if this represents a healing ulcer or neoplasm.  Several biopsies were taken.  The mass was soft.  The pylorus was then entered.  The duodenal bulb and sweep were examined.  There was no evidence of mass, ulceration, or bleeding.  The scope was then brought back into the antrum and was retroflexed.  In the fundus and body, there was evidence of streaking and inflammation.  There were also several small sessile polyps, which were removed with biopsy forceps.  Biopsy was also taken for CLO.  A hiatal hernia was present as well.  Air was aspirated.  The scope was slowly withdrawn.  The GE junction was unremarkable.  The scope was fully withdrawn.  The patient tolerated the procedure well and was transferred to recovery room in stable condition.  She will undergo a CAT scan of her abdomen and pelvis to further assess any possible adenopathy or gastric obstructional changes.  We will await the biopsy reports and further recommendations will follow.
---
DESCRIPTION: EGD and colonoscopy.  Blood loss anemia, normal colon with no evidence of bleeding, hiatal hernia, fundal gastritis with polyps, and antral mass.

gastroenterology, esophagus, gastroscope, hypopharynx, rectum, fundal gastritis, antral mass, hiatal hernia, egd, hernia, polyps, colonoscopy,

The situation involves a 66-year-old patient undergoing EGD and colonoscopy due to blood loss anemia and changes in mental status. The findings of an antral mass that could represent a healing ulcer or neoplasm, along with fundal gastritis and polyps, are concerning because they could indicate a potentially serious condition, such as cancer. This elevates the stakes since early diagnosis and treatment are critical. Additionally, the patient has experienced significant weight loss, further indicating a high level of concern. The need for further testing, such as a CAT scan and awaiting biopsy results, suggests the possibility of a high-impact medical condition.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Low-Transverse C-Section - 2

PREOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy at 37 plus weeks, nonreassuring fetal heart rate.,2.  Protein S low.,3.  Oligohydramnios.,POSTOPERATIVE:,1.  Intrauterine pregnancy at 37 plus weeks, nonreassuring fetal heart rate.,2.  Protein S low.,3.  Oligohydramnios.,4.  Delivery of a viable female, weight 5 pound, 14 ounces.  Apgars of 9 and 9 at 1 and 5 minutes respectively and cord pH is 7.314.,OPERATION PERFORMED:,  Low transverse C-section.,ESTIMATED BLOOD LOSS: , 500 mL.,DRAINS: , Foley.,ANESTHESIA: , Spinal with Duramorph.,HISTORY OF PRESENT ILLNESS:  ,This is a 21-year-old white female gravida 1, para 0, who had presented to the hospital at 37-3/7 weeks for induction.  The patient had oligohydramnios and also when placed on the monitor had nonreassuring fetal heart rate with late deceleration.  Due to the IUGR as well a decision for a C-section was made.,PROCEDURE: , The patient was taken to the operating room and placed in a seated position with standard spinal form of anesthesia administered by the Anesthesia Department.  The patient was then repositioned, prepped and draped in a slight left lateral tilt.  Once this was completed first knife was used to make a low transverse skin incision approximately two fingerbreadths above the pubic symphysis.  This was extended down to the level of the fascia.  The fascia was nicked in the center and extended in transverse fashion.  Edges of the fascia were grasped with Kocher and both blunt and sharp dissection both caudally and cephalic was completed consistent with the Pfannenstiel technique.  The abdominal rectus muscle was divided in the center, extended in vertical fashion and the peritoneum was entered at a high point and extended in vertical fashion.  Bladder blade was put in place and a bladder flap was created with the use of Metzenbaum and pickups and then bluntly dissected via cautery and reincorporated in the bladder blade.  Second knife was used to make a low transverse uterine incision with care being taken to avoid the presenting part of fetus.  Presenting part was vertex, the head was delivered, followed by the remaining portion of the body.  The mouth and nose were suctioned through bulb syringe and the cord was doubly clamped and cut and then the newborn handed off to waiting nursing personnel.  Cord pH blood and cord blood was obtained.  The placenta was delivered manually and the uterus was externalized and the lining was cleaned off any remaining placental fragments and blood and the incisional edges were reapproximated with 0-chromic and a continuous locking stitch with a second layer used to imbricate the first.  The bladder flap was re-peritonized with Gelfoam underneath and abdomen was irrigated with copious amounts of saline and the uterus was placed back in its anatomical position.  The gutters were wiped clean of any remaining blood and fluid and the edges of the perineum grasped with hemostats and continuous locking stitches of 2-0 Vicryl was used to reapproximate the abdominal rectus muscle as well as the perineum.  This area was then irrigated.  Cautery was used for adequate hemostasis, corners of the fascia grasped with hemostats and continuous locking stitch of 1-Vicryl was started at both corners and overlapped in the center.  Subcutaneous tissue was irrigated with saline and reapproximated with 3-0 Vicryl.  Skin edges reapproximated with sterile staples.  Sterile dressing was applied.  The uterus was evacuated of any remaining clots vaginally.  The patient was taken to recovery room in stable condition.  Instrument count, needle count, and sponge counts were all correct.
---
DESCRIPTION: Intrauterine pregnancy at 37 plus weeks, nonreassuring fetal heart rate.

obstetrics / gynecology, apgars, low transverse c section, fetal heart rate, bladder blade, intrauterine pregnancy, intrauterine

This situation involves a C-section due to a nonreassuring fetal heart rate and oligohydramnios, both of which indicate potential distress for the fetus. The stakes are high because the well-being of both the mother and baby can be at risk. Managing fetal distress and ensuring a safe delivery are critical tasks for the healthcare team. This is compounded by the need for rapid decision-making and effective medical intervention to prevent complications. The outcome was successful, with the delivery of a healthy baby and stable condition of the mother, but the potential for serious consequences if not managed well makes it a high-stakes situation.


Medical Specialty: Physical Medicine - Rehab
Sample Name: EMG/Nerve Conduction Study - 3

HISTORY: , The patient is a 56-year-old right-handed female with longstanding intermittent right low back pain, who was involved in a motor vehicle accident in September of 2005.  At that time, she did not notice any specific injury.  Five days later, she started getting abnormal right low back pain.  At this time, it radiates into the buttocks down the posterior aspect of her thigh and into the right lateral aspect of her calf.  Symptoms are worse when sitting for any length of time, such as driving a motor vehicle.  Mild symptoms when walking for long periods of time.  Relieved by standing and lying down.  She denies any left leg symptoms or right leg weakness.  No change in bowel or bladder function.  Symptoms have slowly progressed.  She has had Medrol Dosepak and analgesics, which have not been very effective.  She underwent a spinal epidural injection, which was effective for the first few hours, but she had recurrence of the pain by the next day.  This was done four and a half weeks ago.,On examination, lower extremities strength is full and symmetric.  Straight leg raising is normal.,OBJECTIVE:,  Sensory examination is normal to all modalities.  Full range of movement of lumbosacral spine.  Mild tenderness over lumbosacral paraspinal muscles and sacroiliac joint.  Deep tendon reflexes are 2+ and symmetric at the knees, 2 at the left ankle and 1+ at the right ankle.,NERVE CONDUCTION STUDIES:,  Motor and sensory distal latencies, evoked response, amplitudes, conduction velocities, and F-waves are normal in the lower extremities.  Right tibial H-reflex is slightly prolonged when compared to the left tibial H-reflex.,NEEDLE EMG:,  Needle EMG was performed in both lower extremities and lumbosacral paraspinal muscles using the disposable concentric needle.  It revealed increased insertional activity in the right mid and lower lumbosacral paraspinal muscles as well as right peroneus longus muscle.  There were signs of chronic denervation in right tibialis anterior, peroneus longus, gastrocnemius medialis, and left gastrocnemius medialis muscles.,IMPRESSION: , This electrical study is abnormal.  It reveals the following:,1.  A mild right L5 versus S1 radiculopathy.,2.  Left S1 nerve root irritation.  There is no evidence of active radiculopathy.,3.  There is no evidence of plexopathy, myopathy or peripheral neuropathy.,MRI of the lumbosacral spine was personally reviewed and reveals bilateral L5-S1 neuroforaminal stenosis, slightly worse on the right.  Results were discussed with the patient and her daughter.  I would recommend further course of spinal epidural injections with Dr. XYZ.  If she has no response, then surgery will need to be considered.  She agrees with this approach and will followup with you in the near future.
---
DESCRIPTION: A right-handed female with longstanding intermittent right low back pain, who was involved in a motor vehicle accident with no specific injury at that time.

physical medicine - rehab, emg, nerve conduction study, radiculopathy, peripheral neuropathy, nerve root irritation, motor vehicle accident, lumbosacral paraspinal muscles, spinal epidural, lumbosacral spine, peroneus longus, gastrocnemius medialis, lower extremities, emg/nerve, conduction, needle

The situation involves a patient with chronic pain following a motor vehicle accident, with symptoms that impact her daily life, such as pain while sitting and driving. The electromyography and nerve conduction studies point to specific nerve root issues, and there is a consideration for surgery if further conservative treatments do not bring relief. While the case is important for the patient's quality of life, it does not involve immediate life-threatening conditions, and the patient is showing some agreement with the proposed treatment plan. Thus, while it significantly impacts the patient's lifestyle and well-being, it is not a critical high-stakes situation requiring urgent medical intervention.


Medical Specialty: Consult - History and Phy.
Sample Name: OB/GYN - H&P

CHIEF COMPLAINT,:  This 32 year-old female presents today for an initial obstetrical examination.  Home pregnancy test was positive.,The patient indicates fetal activity is not yet detected (due to early stage of pregnancy).  LMP:  02/13/2002 EDD:  11/20/2002 GW:  8.0 weeks.  Patient has been trying to conceive for 6 months.,Menses:  Onset:  12 years old.  Interval:  24-26 days.  Duration:  4-6 days.  Flow:  moderate.  Complications:  PMS - mild.,Last Pap smear taken on 11/2/2001.  Contraception:  Patient is currently using none.,ALLERGIES:,  Patient admits allergies to venom - bee/wasp resulting in difficulty breathing, severe rash, pet dander resulting in nasal stuffiness.  Medication History:  None.,PAST MEDICAL HISTORY:,  Past medical history is unremarkable.  Past Surgical History:  Patient admits past surgical history of tonsillectomy in 1980.  Social History:  Patient admits alcohol use Drinking is described as social, Patient denies illegal drug use, Patient denies STD history, Patient denies tobacco use.,FAMILY HISTORY:,  Patient admits a family history of cancer of breast associated with mother.,REVIEW OF SYSTEMS:,Neurological: (+) unremarkable.,Respiratory: (+) difficulty sleeping, (-) breathing difficulties, respiratory symptoms.,Psychiatric: (+) anxious feelings.,Cardiovascular: (-) cardiovascular problems or chest symptoms.,Genitourinary: (-) decreased libido, (-) vaginal dryness, (-) vaginal bleeding.  Diet is high in empty calories, high in fats and low in fiber.,PHYSICAL EXAM:,  BP Standing:  126/84 Resp:  22 HR:  78 Temp:  99.1 Height:  5 ft.  6 in.  Weight:  132 lbs.,Pre-Gravid Weight is 125 lbs.,Patient is a 32 year old female who appears pleasant, in no apparent distress, her given age, well developed,,well nourished and with good attention to hygiene and body habitus.,Oriented to person, place and time.,Mood and affect normal and appropriate to situation.,HEENT:Head & Face:  Examination of head and face is unremarkable.,Skin:  No skin rash, subcutaneous nodules, lesions or ulcers observed.  No edema observed.,Cardiovascular:  Heart auscultation reveals no murmurs, gallop, rubs or clicks.,Respiratory:  Lungs CTA.,Breast:  Chest (Breasts):  Breast inspection and palpation shows no abnormal findings.,Abdomen:  Abdomen soft, nontender, bowel sounds present x 4 without palpable masses.,Genitourinary:  External genitalia are normal in appearance.  Examination of urethra shows no abnormalities.  Examination of vaginal vault reveals no abnormalities.  Cervix shows no pathology.  Uterine portion of bimanual exam reveals contour normal, shape regular and size normal.  Adnexa and parametria show no masses, tenderness, organomegaly or nodularity.  Examination of anus and perineum shows no abnormalities.,TEST RESULTS: , Urine pregnancy test:  positive. CBC results within normal limits.  Blood type:  O positive.  Rh:  positive.  FBS:  88 mg/dl.,IMPRESSION:,  Pregnancy, normal first.  Maternal nutrition is inadequate for protein and poor and high in empty calories and junk foods and sweets.,PLAN:,  Pap smear submitted for manual screening.  Ordered CBC.  Ordered blood type.  Ordered hemoglobin.  Ordered Rh.,Ordered fasting blood glucose.,COUNSELING:,  Counseling was given regarding adverse effects of alcohol, physical activity and sexual activity.  Educational supplies dispensed to patient.,Return to clinic in 4 week (s).,PRESCRIPTIONS:,  NatalCare Plus Dosage:  Prenatal Multivitamins tablet Sig:  QD Dispense:  60 Refills:  4 Allow Generic:  Yes,PATIENT INSTRUCTIONS:,  Patient received written information regarding pre-eclampsia and eclampsia.  Patient was instructed to restrict activity.  Patient instructed to limit caffeine use.  Patient instructed to limit salt intake.
---
DESCRIPTION: Initial obstetrical examination - Normal first pregnancy.  Inadequate naternal nutrition.

The scenario describes a standard initial obstetrical examination for a 32-year-old woman in the early stages of a normal first pregnancy. While there are some concerns about inadequate maternal nutrition and lifestyle adjustments, these are not unusual challenges and are being managed with counseling and prescriptions. The situation does not involve any acute medical emergency, life-threatening conditions, or high-risk factors (e.g., severe complications in the pregnancy). Therefore, the stakes, while important, are not extremely high. It is a routine medical scenario that requires ongoing monitoring.


Medical Specialty: Physical Medicine - Rehab
Sample Name: Physical Therapy - Ankle Sprain

DIAGNOSIS: , Ankle sprain, left ankle.,HISTORY: , The patient is a 31-year-old female who was referred to Physical Therapy secondary to a fall on 10/03/08.  The patient states that she tripped over her dog toy and fell with her left foot inverted.  The patient states that she received a series of x-rays and MRIs that were unremarkable.  After approximately 1 month, the patient continued to have significant debilitating pain in her left ankle.  She then received a walking boot and has been in the boot for the past month.,PAST MEDICAL HISTORY: , Significant for hypertension, asthma, and cervical cancer.  The cervical cancer was diagnosed as 15 years old.  The patient states that her cancer is "dormant.",MEDICATIONS:,1.  Hydrochlorothiazide.,2.  Lisinopril.,3.  Percocet.,The patient states that the Percocet helps to take the edge of her pain, but does not completely eliminate it.,SUBJECTIVE: , The patient rates the pain at 2/10 on the pain analog scale.  The patient states that with elevation and rest, her pain subsides.,FUNCTIONAL ACTIVITIES/HOBBIES: , Currently limited including basic household chores and activities, this does increases her pain.  The patient states she also recently joined Weight Watchers and was involved in a walking routine and is currently unable to participate in this activity.,WORK STATUS: , The patient is currently on medical leave as a paraprofessional.  The patient states that she works as a teacher's aide in the school system and is required to complete extensive walking and standing activities.  The patient states that she is primarily on her feet while at work and rarely has a sitting break for extensive period of time.  The patient's goal is to be able to stand and walk without pain.,SOCIAL HISTORY:  ,The patient lives in a private home with children and her father.  The patient states that she does have stairs to negotiate without the use of a railing.  She states that she is able to manage the stairs, however, is very slow with her movement.  The patient smokes 1-1/2 packs of cigarettes a day and does not have a history of regular exercise routine.,OBJECTIVE: , Upon observation, the patient is a very obese female who is ambulating with significant antalgic gait pattern and altered normal gait due to the pain as well as the walking boot.  Upon inspection of the left ankle, it appears to have swelling, unsure if this swelling is secondary to injury or water retention as the patient states she has significant water retention.  When compared to right ankle edema, it is approximately equal.  There is no evidence of discoloration or temperature.  The patient states that she had no bruising at the time of injury.,Active range of motion of left ankle is as follows:  Dorsiflexion is 6 degrees past neutral and plantar flexion is 54 degrees, eversion 20 degrees, and inversion is 30 degrees.  Left ankle dorsiflexion lacks 10 degrees from neutral and plantar flexion is 36 degrees, this motion is very painful.  The patient was tearful during this activity.  Eversion is 3 degrees and inversion is 25 degrees.  The patient states this movement was difficult, but not painful.  Strength testing of the right lower extremity is grossly 4+-5/5 and left ankle is 2/5 as the patient is unable to obtain full range of motion.,PALPATION: , The patient is very tender to palpation primarily along the lateral malleolus of the left ankle.,JOINT PLAY: , Unable to be assessed secondary to the patient's extreme tenderness and guarding of the ankle joint.,SPECIAL TESTS:,  A 6-minute walk test.  The patient was able to ambulate approximately 600 feet while wearing her walking boot prior to her pain significantly increasing in the ankle and requiring the test to be stopped.,ASSESSMENT:  ,The patient would benefit from skilled physical therapy intervention as a trial of treatment in order to address the following problem list:,1.  Increased pain.,2.  Decreased range of motion.,3.  Decreased strength.,4.  Decreased ability to complete work task and functional activities in the home.,5.  Decreased gait pattern.,SHORT-TERM GOALS TO BE COMPLETED IN 3 WEEKS:,1.  The patient will demonstrate independence with home exercise program.,2.  The patient will ambulate without her boot for 48 hours in order to decrease reliance upon the boot for ankle stabilization.,3.  The patient will achieve left ankle dorsiflexion to neutral and plantar flexion to 45 degrees without significant increase in pain.,4.  The patient will demonstrate 3/5 strength of the left ankle.,5.  The patient will tolerate the completion of the 6-minute walk test without the use of a boot with minimal increase in pain.,LONG-TERM GOALS TO BE COMPLETED IN 6 WEEKS:,1.  The patient will report 0/10 pain in the 48-hour period without the use of medication and without wearing her boot.,2.  The patient will return to go through the work without the use of the walking boot with report of minimal increase in pain and discomfort.,PROGNOSIS:,  Fair for above-stated goals with full compliance to home exercise program and therapy treatment as well as the patient motivation.,PLAN: , The patient to be seen three times a week for 6 weeks for the following:
---
DESCRIPTION: Ankle sprain, left ankle.  The patient tripped over her dog toy and fell with her left foot inverted.  The patient states that she received a series of x-rays and MRIs that were unremarkable.  After approximately 1 month, the patient continued to have significant debilitating pain in her left ankle.  She then received a walking boot and has been in the boot for the past month.

The situation involves a patient who has an ankle sprain that has persisted in causing significant pain and limitation in mobility for about two months. While the injury itself is not life-threatening and is a common type of physical injury treated in physical therapy, it has substantially impacted the patient's quality of life and ability to work. The patient's work involves significant standing and walking, which they are currently unable to perform. However, considering the injury’s nature and the planned treatment, this situation is not high-stakes in a medical or life-threatening sense, but it does have considerable implications for the patient's daily life and occupational functioning.


Medical Specialty: ENT - Otolaryngology
Sample Name: Uvulopalatopharyngoplasty & Tonsillectomy

PREOPERATIVE DIAGNOSIS:,  Obstructive sleep apnea.,POSTOPERATIVE DIAGNOSIS:  ,Obstructive sleep apnea.,PROCEDURE PERFORMED:,1.  Tonsillectomy.,2.  Uvulopalatopharyngoplasty.,ANESTHESIA:,  General endotracheal tube.,BLOOD LOSS: , Approximately 50 cc.,INDICATIONS: , The patient is a 41-year-old gentleman with a history of obstructive sleep apnea who has been using CPAP, however, he was not tolerating used of the machine and requested a surgical procedure for correction of his apnea.,PROCEDURE: , After all risks, benefits, and alternatives have been discussed with the patient, informed consent was obtained.  The patient was brought to the operative suite where he was placed in supine position and general endotracheal tube intubation was delivered by the Department of Anesthesia.  The patient was rotated 90 degrees away and a shoulder roll was placed and a McIvor mouthgag was inserted into the oral cavity.  Correct inspection and palpation did not reveal evidence of a bifid uvula or submucosal clots.  Attention was directed first to the right tonsil in which a curved Allis forceps was applied to the superior pole.  The needle-tip Bovie cautery was used to incise the mucosa of the anterior tonsillar pillar.  Once the tonsillar pillar was identified and the superior pole was released, the curved forceps with a straight Allis forceps and the dissection was carried down inferiorly, dissecting the tonsil free from all fascial attachments.  Once the tonsil was delivered from the oral cavity, hemostasis was obtained within the tonsillar fossa utilizing suction cautery.,Attention was then directed over to the left tonsil in which a similar procedure was performed.  Once all bleeding was controlled, the mucosa of both the hard and soft palate was anesthetized with a mixture of 1% lidocaine and 1:50000 epinephrine solution.  Now attention was directed to the posterior pillars.  A hemostat was used to clamp the posterior pillar, which was then taken down with Metzenbaum scissors.  The posterior pillar was then approximated to the anterior pillar with the use of #3-0 PDS suture so as to create a box shaped soft palate.  Now, the uvula was reflected onto the soft palate and #12 blade scalpel was used to incise the mucosa of the soft palate extending down onto the uvula.  The mucosa was dissected off with the use of Potts scissors.  Now the uvula was reflected onto the soft palate and sutured down in place with use of #3-0 PDS suture approximated with deep muscle layers.  Now the mucosa of the soft palate and the uvula were approximated with interrupted #3-0 PDS sutures.  Finally, #4-0 Vicryl sutures were placed intermittently between the PDS to further secure the uvula, which had been reflected onto the soft palate.  A final #3-0 PDS suture was used to further approximate the anterior and posterior tonsil pillars.  Final inspection did not reveal any further bleeding.  The mouth was then irrigated with saline and suctioned.  At this point, the procedure was complete.  He was awakened and taken to recovery room in stable condition.  He will be admitted as an observation patient to the Telemetry Floor for routine postoperative management.  Of note, IV Decadron was administered during the procedure.
---
DESCRIPTION: Uvulopalatopharyngoplasty and tonsillectomy.   The patient with a history of obstructive sleep apnea who has been using CPAP, however, he was not tolerating used of the machine and requested a surgical procedure for correction of his apnea.

ent - otolaryngology, endotracheal, metzenbaum, soft palate, obstructive sleep apnea, tonsillectomy, uvulopalatopharyngoplasty, obstructive, mucosa, uvula, palate,

The situation describes a surgical procedure (Uvulopalatopharyngoplasty and tonsillectomy) for a patient with obstructive sleep apnea who cannot tolerate CPAP therapy. While surgery always involves some risk, this type of procedure is relatively routine for ENT specialists and is indicated due to the patient's inability to tolerate CPAP. The documented blood loss is minimal, and there were no complications during the procedure. The stakes are moderate due to the general anesthesia and the importance of resolving sleep apnea, which can have significant effects on health if untreated, but it is not an emergency or highly complex surgery.


Medical Specialty: Orthopedic
Sample Name: CT of Lumbar Spine w/o Contrast

EXAM: , Lumbar spine CT without contrast.,HISTORY: , Back pain after a fall.,TECHNIQUE:,  Noncontrast axial images were acquired through the lumbar spine. Coronal and sagittal reconstruction views were also obtained.,FINDINGS: , There is no evidence for acute fracture or subluxation.  There is no spondylolysis or spondylolisthesis.  The central canal and neuroforamen are grossly patent at all levels.  There are no abnormal paraspinal masses. There is no wedge/compression deformity.  There is intervertebral disk space narrowing to a mild degree at L2-3 and L4-5.,Soft tissue windows demonstrate atherosclerotic calcification of the abdominal aorta, which is not dilated.  There was incompletely visualized probable simple left renal cyst, exophytic at the lower pole.,IMPRESSION:,1.  No evidence for acute fracture or subluxation.,2.  Mild degenerative changes.,3.  Probable left simple renal cyst.,
---
DESCRIPTION: CT of Lumbar Spine without Contrast.  Patient with history of back pain after a fall.

orthopedic, lumbar spine, back pain, ct, coronal, atherosclerotic, axial images, central canal, compression, deformity, degenerative, disk space, fracture, intervertebral, neuroforamen, sagittal, spondylolisthesis, spondylolysis, subluxation, wedge, without contrast, contrast, spine, lumbar, noncontrast,

The CT scan results for the lumbar spine indicate no acute fractures or critical issues. The findings note mild degenerative changes and a probable simple renal cyst, conditions that are generally not life-threatening. The lack of acute findings reduces the urgency of the situation, making it low-stakes in the context of immediate medical interventions. However, further clinical evaluation or monitoring could be necessary for the degenerative changes and renal cyst.