Medical Specialty: Urology
Sample Name: Prostatectomy

PREOPERATIVE DIAGNOSIS:,  Prostate cancer, Gleason score 4+3 with 85% burden and 8/12 cores positive.,POSTOPERATIVE DIAGNOSIS:,  Prostate cancer, Gleason score 4+3 with 85% burden and 8/12 cores positive.,PROCEDURE DONE: , Open radical retropubic prostatectomy with bilateral lymph node dissection.,INDICATIONS:,  This is a 66-year-old gentleman who had an elevated PSA of 5.  His previous PSAs were in the 1 range.  TRUS biopsy revealed 4+3 Gleason score prostate cancer with a large tumor burden.  After extensive counseling, the patient elected for retropubic radical prostatectomy.  Given his disease burden, it was advised that an open prostatectomy is probably the standard of care to ensure entire excision.  The patient consented and agreed to proceed forward.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating room here.  Time out was taken to properly identify the patient and procedure going to be done.  General anesthesia was induced.  The patient was placed in the supine position.  The bed was flexed distant to the pubic area.  The patient's lower abdominal area, pubic area, and penile and scrotal area were clipped, and then scrubbed with Hibiclens soap for three minutes.  The patient was then prepped and draped in normal sterile fashion.  Foley catheter was inserted sterilely in the field.  Preoperative antibiotics were given within 30 minutes of skin incision.  A 10 cm lower abdominal incision was made from the symphysis pubis towards the umbilicus.  Dissection was taken down through Scarpa's fascia to the level of the anterior rectus sheath.  The rectus sheath was then incised and the muscle was split in the middle.  Space of rectus sheath was then entered.  The Bookwalter ring was then applied to the belly, and the bladder was then retracted to the right side, thus exposing the left obturator area.  The lymph node packet on the left side was then dissected.  This was done in a split and roll fashion with the flimsy tissue, and the left external iliac vein was incised, and the tissues were then rolled over the left external iliac vein.  Dissection was carried down from the left external iliac vein to the obturator nerve and up to the level of the pelvic sidewall.  The proximal extent of dissection was the left hypogastric artery to the level of the node of Cloquet distally.  Care was taken to avoid injury to the nerves.  An accessory obturator vein was noted and was ligated.  The same procedure was done on the right side with dissection of the right obturator lymph node packet, which was sent for pathologic evaluation.  The bladder subsequently was retracted cephalad.  The prostate was then defatted up to the level of the endopelvic fascia.  The endopelvic fascia was then incised bilaterally, and the incision was then taken to the level of the puboprostatic ligaments.  Vicryl stitch was then applied at the level of the bladder neck in order to control the bladder back bleeders.  A Babcock was then applied around the dorsal venous complex over the urethra and the K-wire was then passed between the dorsal vein complex and the urethra by passing by the aid of a right angle.  A 0-Vicryl stitch was then applied over the dorsal venous complex, which was then tied down and cinched to the symphysis pubis.  Using a knife on a long handle, the dorsal venous complex was then incised using the K-wire as a guide.  Following the incision of the dorsal venous complex, the anterior urethra was then incised, thus exposing the Foley catheter.  The 3-0 Monocryl sutures were then applied going outside in on the anterior aspect of the urethra.  The lateral edges of the urethra were also then incised, and two lateral stitches were also applied going outside end.  The catheter was then drawn back at the level of membranous urethra, and a final posterior stitch was applied going outside end.  The urethra was subsequently divided in its entirety.  A Foley catheter was then taken out and was inserted directly into the bladder through the prostatic apex.  The prostate was then entered cephalad, and the prostatic pedicles were then systematically taken down with the right angle clips and cut.  Please note that throughout the case, the patient was noted to have significant oozing and bleeding partially from the dorsal venous complex, pelvic veins, and extensive vascularity that was noted in the patient's pelvic fatty tissue.  Throughout the case, the bleeding was controlled with the aid of a clips, Vicryl sutures, silk sutures, and ties, direct pressure packing, and FloSeal.  Following the excision of the prostatic pedicles, the posterior dissection at this point was almost complete.  Please note that the dissection was relatively technically challenging due to extensive adhesions between the prostate and Denonvilliers' fascia.  The seminal vesicle on the left side was dissected in its entirety; however, the seminal vesicle on the right side was adherently stuck to the Denonvilliers' fascia, which prompted the excision of most of the right seminal vesicle with the exception of the tip.  Care was taken throughout the posterior dissection to preserve the integrity of the ureters.  The anterior bladder neck was then cut anteriorly, and the bladder neck was separated from the prostate.  Following the dissection, the 5-French feeding tubes were inserted bilaterally into the ureters thus insuring their integrity.  Following the dissection of the bladder from the prostate, the prostate at this point was mobile and was sent for pathological evaluation.  The bladder neck was then repaired using Vicryl in a tennis racquet fashion.  The rest of the mucosa was then everted.  The ureteral orifices and ureters were protected throughout the procedure.  At this point, the initial sutures that were applied into the urethra were then applied into the corresponding position on the bladder neck, and the bladder neck was then cinched down and tied down after a new Foley catheter was inserted through the penile meatus and into the bladder pulling the bladder in position.  Hemostasis was then adequately obtained.  FloSeal was applied to the pelvis.  The bladder was then irrigated.  It was draining pink urine.  The wound was copiously irrigated.  The fascia was then closed using a #1 looped PDS.  The skin wound was then irrigated, and the skin was closed with a 4-0 Monocryl in subcuticular fashion.  At this point, the procedure was terminated with no complications.  The patient was then extubated in the operating room and taken in stable condition to the PACU.  Please note that during the case about 3600 mL of blood was noted.  This was due to the persistent continuous oozing from vascular fatty tissue and pelvic veins as previously noted in the dictation.
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DESCRIPTION: Open radical retropubic prostatectomy with bilateral lymph node dissection.

urology, bilateral lymph node dissection, retropubic prostatectomy, radical retropubic prostatectomy, gleason score, prostate cancer, trus, biopsy, bilateral lymph node, lymph node dissection, catheter was inserted, bilateral lymph, node dissection, vicryl stitch, prostatic pedicles, pelvic veins, external iliac, iliac vein, seminal vesicle, lymph node, foley catheter, dorsal venous, venous complex, bladder neck, dissection, prostatectomy, bladder, endopelvic, vicryl, catheter, vein, venous, fascia, dorsal, urethra,

The situation involves a major surgical procedure for the treatment of prostate cancer, specifically a radical prostatectomy with lymph node dissection. This is a high-stakes scenario due to several factors: the complexity of the surgery, the significant blood loss occurring during the procedure, and the overall critical nature of treating cancer. The surgical intervention aims to remove cancerous tissues and prevent metastasis, which is crucial for the patient's prognosis. The detailed description highlights the technical challenges and the measures taken to control bleeding, underscoring the critical importance of successfully performing the surgery to maintain patient safety and ensure optimal outcomes.


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

Medical Specialty: Cardiovascular / Pulmonary
Sample Name: CABG - Redo

OPERATIVE PROCEDURE:,1.  Redo coronary bypass grafting x3, right and left internal mammary, left anterior descending, reverse autogenous saphenous vein graft to the obtuse marginal and posterior descending branch of the right coronary artery.  Total cardiopulmonary bypass, cold-blood potassium cardioplegia, antegrade for myocardial protection.,2.  Placement of a right femoral intraaortic balloon pump.,DESCRIPTION: , The patient was brought to the operating room and placed in the supine position.  After adequate endotracheal anesthesia was induced, appropriate monitoring lines were placed.  Chest, abdomen an legs were prepped and draped in sterile fashion.  The femoral artery on the right was punctured and a guidewire was placed.  The track was dilated and intraaortic balloon pump was placed in the appropriate position, sewn in place and ballooning started.,The left greater saphenous vein was harvested from the groin to the knee and prepared by ligating all branches with 4-0 silk and flushed with vein solution.  The leg was closed with running 3-0 Dexon subcu and running 4-0 Dexon on the skin.,The old mediastinal incision was opened.  The wires were cut and removed.  The sternum was divided in the midline.  Retrosternal attachments were taken down.  The left internal mammary was dissected free from its takeoff at the left subclavian bifurcation at the diaphragm and surrounded with papaverine-soaked gauze.  The heart was dissected free of its adhesions.  The patient was fully heparinized and cannulated with a single aorta and single venous cannula.  Retrograde cardioplegia cannula was attempted to be placed, but could not be fitted into the coronary sinus safely, therefore, it was banded and oversewn with 5-0 Prolene.  An antegrade cardioplegia needle sump was placed and secured to the ascending aorta.  Cardiopulmonary bypass ensued.  The ascending aorta was cross clamped.  Cold-blood potassium cardioplegia was given antegrade, a total of 10 cc/kg.  It was followed by sumping the ascending aorta.  The obtuse marginal was identified and opened and an end-to-side anastomosis was performed with a running 7-0 Prolene suture.  The vein was cut to length.  Antegrade cardioplegia was given, a total of 200 cc.  The posterior descending branch of the right coronary artery was identified, opened and end-to-side anastomosis then performed with a running 7-0 Prolene suture.  The vein was cut to length.  Antegrade cardioplegia was given.  The mammary was clipped distally, divided and spatulated for anastomosis.  The anterior descending was identified, opened and end-to-side anastomosis then performed with running 8-0 Prolene suture and warm blood potassium cardioplegia was given.  The cross clamp was removed.  A partial-occlusion clamp was placed.  Aortotomies were made.  The vein was cut to fit these and sutured in place with running 5-0 Prolene suture.  The partial-occlusion clamp was removed.  All anastomoses were inspected and noted to be patent and dry.  Atrial and ventricular pacing wires were placed.  The patient was fully warmed and ventilation was commenced.  The patient was weaned from cardiopulmonary bypass, ventricular balloon pumping and inotropic support and weaned from cardiopulmonary bypass.  The patient was decannulated in routine fashion.  Protamine was given.  Good hemostasis was noted.  A single mediastinal chest tube and bilateral pleural Blake drains were placed.  The sternum was closed with figure-of-eight stainless steel wire.  The linea alba was closed with figure-of-eight of #1 Vicryl, the sternal fascia closed with running #1 Vicryl, the subcu closed with running 2-0 Dexon, skin with running 4-0 Dexon subcuticular stitch.  The patient tolerated the procedure well.
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DESCRIPTION: Redo coronary bypass grafting x3, right and left internal mammary, left anterior descending, reverse autogenous saphenous vein graft to the obtuse marginal and posterior descending branch of the right coronary artery.  Total cardiopulmonary bypass, cold-blood potassium cardioplegia, antegrade for myocardial protection.  Placement of a right femoral intraaortic balloon pump.

cardiovascular / pulmonary, coronary bypass grafting, internal mammary, cardiopulmonary, intraaortic, femoral artery, cabg, running prolene suture, intraaortic balloon, balloon pump, ascending aorta, prolene suture, cardiopulmonary bypass, potassium, aorta, anastomosis, prolene, coronary, cardioplegia, bypass,

The given situation involves a complex cardiac surgery procedure known as 'Redo coronary bypass grafting.' This type of surgery is high-stakes due to the inherent risks associated with heart surgery, potential complications during the procedure, and the critical nature of the cardiovascular system. The procedure description indicates several significant interventions, including cardiopulmonary bypass, which are used in high-risk surgeries. Additionally, the need for myocardial protection and the use of an intraaortic balloon pump imply a critical condition that further elevates the stakes.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: General Medicine
Sample Name: Gen Med SOAP - 3

S:,  XYZ is in today not feeling well for the last three days.  She is a bit sick with bodyaches.  She is coughing.  She has a sore throat, especially when she coughs.  Her cough is productive of green colored sputum.  She has had some chills.  No vomiting.  No diarrhea.  She is sleeping okay.  She does not feel like she needs anything for the cough.  She did call in yesterday, and got a refill of her Keflex.  She took two Keflex this morning and she is feeling a little bit better now.  She is tearful, just tired of feeling ran down.,O:,  Vital signs as per chart.  Respirations 15.  Exam:  Nontoxic.  No acute distress.  Alert and oriented.  HEENT:  TMs are clear bilaterally without erythema or bulging.  Clear external canals.  Clear tympanic.  Conjunctivae are clear.  Clear nasal mucosa.  Clear oropharynx with moist mucous membranes.  NECK is soft and supple without lymphadenopathy.  LUNGS are coarse with no severe rhonchi or wheezes.  HEART is regular rate and rhythm without murmur.  ABDOMEN is soft and nontender.,Chest x-ray reveals no obvious consolidation or infiltrates.  We will send the x-ray for over-read.,Influenza test is negative.  Rapid strep screen is negative.,A:,  Bronchitis/URI.,P: , ,1.  Motrin as needed for fever and discomfort.,2.  Push fluids.,3.  Continue on the Keflex.,4.  Follow up with Dr. ABC if symptoms persist or worsen, otherwise as needed.
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DESCRIPTION: General Medicine SOAP note.

General Medicine SOAP note.

general medicine, bodyaches, alert and oriented, no acute distress, soap, diarrhea, lymphadenopathy, regular rate and rhythm, rhonchi, soft and nontender, supple, vomiting, wheezes, coughing, keflex, oriented,

The situation described in the SOAP note indicates a patient experiencing common symptoms of a respiratory infection, likely bronchitis or an upper respiratory infection (URI). The vital signs are stable, and tests for influenza and strep are negative. The patient is receiving typical care, including supportive treatments such as Motrin for discomfort, fluid intake, and antibiotics (Keflex). The absence of severe symptoms or a positive test for more serious conditions suggests that this is a routine, low-risk medical encounter.


Medical Specialty: General Medicine
Sample Name: Normal ROS Template - 3

HEENT:,  No history of headaches, migraines, vertigo, syncope, visual loss, tinnitus, sinusitis, sore in the mouth, hoarseness, swelling or goiter.,RESPIRATORY: , No shortness of breath, wheezing, dyspnea, pulmonary disease, tuberculosis or past pneumonias.,CARDIOVASCULAR: , No history of palpitations, irregular rhythm, chest pain, hypertension, hyperlipidemia, diaphoresis, congestive heart failure, heart catheterization, stress test or recent cardiac tests.,GASTROINTESTINAL:,  No history of rectal bleeding, appetite change, abdominal pain, hiatal hernia, ulcer, jaundice, change in bowel habits or liver problems, and no history of inflammatory bowel problems.,GENITOURINARY: , No dysuria, hematuria, frequency, incontinence or colic.,NERVOUS SYSTEM: , No gait problems, strokes, numbness or muscle weakness.,PSYCHIATRIC: , No history of emotional lability, depression or sleep disturbances.,ONCOLOGIC:,  No history of any cancer, change in moles or rashes.  No history of weight loss.  The patient has a good energy level.,ALLERGIC/LYMPH: , No history of systemic allergy, abnormal lymph nodes or swelling.,MUSCULOSKELETAL: , No fractures, motor weakness, arthritis or other joint pains.
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DESCRIPTION: Normal review of systems template.  No history of headaches, migraines, vertigo, syncope, visual loss, tinnitus, sinusitis, sore in the mouth, hoarseness, swelling or goiter.

general medicine, review of systems, tinnitus, sinusitis, sore, mouth, hoarseness, goiter, heart, appetite, bowel, weakness, loss, swelling,

The provided template describes a normal review of systems (ROS) for a patient, indicating no significant medical history across various body systems. This is a routine document used by medical practitioners to ensure a comprehensive review of a patient's health status. The information given in this context represents a low-risk situation because it does not highlight any immediate health concerns or urgent medical issues. It is a standard clinical tool to verify a patient's reported health status, rather than a critical or high-stakes scenario.


Medical Specialty: Surgery
Sample Name: Colonoscopy - 12

PROCEDURE IN DETAIL: , Following instructions and completion of an oral colonoscopy prep, the patient, having been properly informed of, with signature consenting to total colonoscopy and indicated procedures, the patient received premedications of Vistaril 50 mg, Atropine 0.4 mg IM, and then intravenous medications of Demerol 50 mg and Versed 5 mg IV.  Perirectal inspection was normal.  The Olympus video colonoscope then was introduced into the rectum and passed by directed vision to the cecum and into the terminal ileum.  No abnormalities were seen of the terminal ileum, the ileocecal valve, cecum, ascending colon, hepatic flexure, transverse colon, splenic flexure, descending colon, rectosigmoid and rectum.  Retroflexion exam in the rectum revealed no other abnormality and withdrawal terminated the procedure.
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DESCRIPTION: Colonoscopy.  The Olympus video colonoscope then was introduced into the rectum and passed by directed vision to the cecum and into the terminal ileum.

surgery, ileocecal valve, cecum, ascending colon, hepatic flexure, transverse colon, splenic flexure, descending colon, rectosigmoid, rectum, terminal ileum, olympus video colonoscope, flexure, colonoscopyNOTE,: 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.,

Colonoscopy is a routine and relatively safe procedure used for diagnosing and sometimes treating conditions of the colon. Although it involves sedation and carries some risk, it is generally considered low-stakes compared to many other surgical procedures. The description indicates no abnormalities were found, further lowering the stakes involved in this particular case. However, as a medical procedure requiring consent and involving sedation, it cannot be rated as the lowest possible stakes.


Medical Specialty: Orthopedic
Sample Name: Wrist Pain

CHIEF COMPLAINT:,  Left wrist pain.,HISTORY OF PRESENT PROBLEM:,
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DESCRIPTION: Consultation for wrist pain.

Consultation for wrist pain.

orthopedic, wrist pain, scapholunate, tenderness to palpation, three views, traumatic wrist injury, ulnar styloid nonunion, ulnar styloid, wrist, union, soreness, styloid, ulnar,

The situation described involves a consultation for wrist pain, which is a common orthopedic issue. While it can be uncomfortable and impact daily activities, wrist pain generally does not pose an immediate threat to life or result in severe consequences. However, it can be indicative of an underlying condition that may need attention. Thus, the stakes are moderate considering the need for a proper diagnosis and treatment to prevent further complications.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Cardiac Catheterization - 9

EXAM: , Cardiac catheterization and coronary intervention report.,PROCEDURES:,1.  Left heart catheterization, coronary angiography, left ventriculography.,2.  PTCA/Endeavor stent, proximal LAD.,INDICATIONS: , Acute anterior ST-elevation MI.,ACCESS: , Right femoral artery 6-French.,MEDICATIONS:,1.  IV Valium.,2.  IV Benadryl.,3.  Subcutaneous lidocaine.,4.  IV heparin.,5.  IV ReoPro.,6.  Intracoronary nitroglycerin.,ESTIMATED BLOOD LOSS: , 10 mL.,CONTRAST:  ,185 mL.,COMPLICATIONS: , None.,PROCEDURE: , The patient was brought to the cardiac catheterization laboratory with acute ST-elevation MI and EKG.  She was prepped and draped in the usual sterile fashion.  The right femoral region was infiltrated with subcutaneous lidocaine, adequate anesthesia was obtained.  The right femoral artery was entered with _______ modified Seldinger technique and a J wire was passed.  The needle was exchanged for 6 French sheath.  The wire was removed.  The sheath was washed with sterile saline.  Following this, the left coronary was attempted to be cannulated with an XP catheter, however, the catheter folded on itself and could not reach the left main, this was removed.  A second 6-French JL4 guiding catheter was then used to cannulate the left main and initial guiding shots demonstrated occlusion of the proximal LAD.  The patient had an ACT check, received additional IV heparin and IV ReoPro.  The lesion was crossed with 0.014 BMW wire and redilated with a 2.5 x 20-mm balloon at nominal pressures.  The balloon was deflated and angiography demonstrated establishment of flow.  Following this, the lesion was stented with a 2.5 x 18-mm Endeavor stent at 10 atmospheres.  The balloon was deflated, reinflated at 12 atmospheres, deflated and removed.  Final angiography demonstrated excellent clinical result.  Additional angiography was performed with a wire out.  Following this, the wire and the catheter was removed.  Following this, the right coronary was selectively cannulated with diagnostic catheter and angiographic views were obtained in multiple views.  This catheter was removed.  The pigtail catheter was placed in the left ventricle and left ventriculography was performed with pullback pressures across the aortic valve.  At the end of procedure, wires and catheter were removed.  Right femoral angiography was performed and a right femoral Angio-Seal kit was deployed at the right femoral arteriotomy site.  There was no hematoma.  Peripheral pulses _______ procedure.  The patient tolerated the procedure well.  Symptoms of chest pain resolved at the end of the procedure with no complications.,RESULTS:,1.  Coronary angiography.,A.  Left main free of obstruction.,B.  LAD, subtotal proximal stenosis.,C.  Circumflex large vessel with three large obtuse marginal branches.  No high-grade obstruction, evidence of minimal plaquing.,D.  Right coronary 70% mid vessel stenosis and 50% mid to distal stenosis before giving rise to a right dominant posterior lateral and posterior descending artery.,2.  Left ventriculogram.  Left ventricular ejection fraction estimated at 45% to 50%.  There was an akinetic apical wall.,3.  Hemodynamics.  Aortic pressure 145/109, left ventricular pressure 147/13, left ventricular end-diastolic pressure 34 mmHg.,IMPRESSION:,1.  Acute ST-elevation myocardial infarction, culprit lesion, left anterior descending occlusion.,2.  Two-vessel coronary disease.,3.  Mild-to-moderate impaired LV systolic function.,4.  Successful stent left anterior descending, 100% occlusion, 0% residual stenosis.,PLAN:  ,Overnight observation in ICU.  Start aspirin, Plavix, beta-blocker and ACE inhibitor.  Check serial cardiac enzymes.  Further recommendations to follow.  Check fasting lipid panel, in addition add a statin.  Further recommendations to follow.
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DESCRIPTION: Cardiac catheterization and coronary intervention report.

This scenario involves a cardiac catheterization and coronary intervention procedure conducted due to an acute ST-elevation myocardial infarction (STEMI). The immediate intervention and successful stenting were necessary to restore blood flow. STEMI is a critical medical condition that, if not treated promptly, can lead to significant morbidity or mortality. Additionally, the details include direct actions taken to address artery occlusion and ongoing monitoring plans in the ICU. These factors mark a high-stakes scenario in the medical context.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Selective Coronary Angiography & Angioplasty

PREOPERATIVE DIAGNOSIS AND INDICATIONS:,  Acute non-ST-elevation MI.,POSTOPERATIVE DIAGNOSIS AND SUMMARY:,  The patient presented with an acute non-ST-elevation MI.  Despite medical therapy, she continued to have intermittent angina.  Angiography demonstrated the severe LAD as the culprit lesion.  This was treated as noted above with angioplasty alone as the stent could not be safely advanced.  She has residual lesions of 75% in the proximal right coronary and 60% proximal circumflex, and the other residual LAD lesions as noted above.  She will be continued on her medical therapy.  At age 90, she is not a good candidate for aortic valve replacement and coronary bypass grafting.,PROCEDURE PERFORMED: , Selective coronary angiography, coronary angioplasty.,PROCEDURE IN DETAIL:,  After informed consent was obtained, the patient was taken to the cath lab, placed on the table in the supine position.  The area of the right femoral artery was prepped and draped in a sterile fashion.  Using the percutaneous technique, a 6-French sheath was placed in the right femoral artery under fluoroscopic guidance.  With the guidewire in place, a 5-French JL-4 catheter was used to selectively angiogram the left coronary system.  The catheter was removed.  The sheath flushed.  The 5-French 3DRC catheter was then used to selectively angiogram the right coronary artery.  The cath removed, the sheath flushed.,It was decided that intervention was needed in the severe lesions in the LAD, which appeared to be the culprit lesions for the non-ST elevation-MI.  The patient was given a bolus of heparin and an ACT of approximately 50 seconds was obtained, we rebolused and the ACT was slightly lower.  We repeated the level and it was slightly higher.  We administered 500 more units of heparin and then proceeded with an ACT of approximately 270 seconds prior to the 500 units of heparin IV.  Additionally, the patient had been given 300 mg of Plavix orally during the procedure and Integrilin IV bolus and then maintenance drip was started.,A 6-French CLS 3.5 left coronary guide catheter was used to cannulate the left main and HEW guidewire was positioned in the distal LAD and another HEW guidewire in the relatively large third diagonal.  An Apex 2.5 x 15 mm balloon was positioned in the distal portion of the mid LAD stenosis and inflated to 6 atmospheres for 15 seconds and then deflated.  Angiography was then performed, demonstrated marked improvement in the stenosis and this image was used for sizing the last of the needed stent.  The balloon was pulled more proximally and then inflated again at 6 atmospheres for approximately 20 seconds, with the proximal end of the balloon positioned distal to the origin of the third diagonal so as to not compromise the ostium.  The balloon was inflated and removed, repeat angiography performed.  We attempted to advance a Driver 2.5 x 24 mm bare metal stent, but I could not advance it beyond the proximal LAD, where there was significant calcification.  The stent was removed.  Attempts to advance the same 2.5 x 15 mm Apex balloon that was previously used were unsuccessful.  It was removed, a new Apex 2.5 x 15 mm balloon was then positioned in the proximal LAD and inflated to 6 atmospheres for 15 seconds and then deflated and advanced slightly with the distal tip of the balloon proximal to the third diagonal ostium and it was inflated to 6 atmospheres for 15 seconds and then deflated and removed.  Repeat angiography demonstrated no evidence of dissection.  One more attempt was made to advance the Driver 2.5 x 24 mm bare metal stent, but again I could not advance it beyond the calcified plaque in the proximal LAD and this was despite the presence of the buddy wire in the diagonal.  I felt that further attempts in this calcified vessel in a 90-year-old with severe aortic stenosis and severe aortic insufficiency would likely result in complications of dissection, so the stent was removed.  The guidewires and guide cath were removed.  The sheath flushed and sutured into position.  The patient moved to ICU in stable condition with no chest discomfort at all.,CONTRAST: , Isovue-370, 120 mL.,FLUORO TIME: , 9.4 minutes.,ESTIMATED BLOOD LOSS: , 30 mL.,HEMODYNAMICS:,  Aorta 185/54.,Left ventriculography was not performed.  I did not make an attempt to cross this severely stenotic aortic valve.,The left main is a large vessel, giving rise to LAD and circumflex vessels.  The left main has no significant disease other than calcification in the walls.,The LAD is a moderate-to-large vessel, giving rise to small diagonals and then a moderate-to-large third diagonal, and then a small fourth diagonal.  The LAD has significant calcification proximally.  There is a 50% stenosis between the first and second diagonals that we treated with angioplasty alone in an attempt to be able to advance the stent.  This resulted in a 30% residual, mostly eccentric calcified plaque.  Following this, there was a 50% stenosis in the LAD just after the takeoff of the third diagonal.  This was not ballooned.  Beyond this is an 80% stenosis prior to the fourth diagonal and then a 99% stenosis after the fourth diagonal.  These 2 lesions were dilated with 10% residual prior to the fourth diagonal and 25% residual distal to the fourth diagonal.  As noted above, this area was not stented because I could not safely advance the stent.  Note, there was also a 50% stenosis at the origin of the moderate-to-large third diagonal that did not change with angioplasty.,The circumflex is a large, nondominant vessel consisting of a large obtuse marginal with multiple branches.  The proximal circumflex has an eccentric 60% stenosis prior to the takeoff of the obtuse marginal.  The remainder of the vessel was without significant disease.,The right coronary was a large, dominant vessel giving rise to a large posterior descending artery and small-to-moderate first posterolateral, small second posterolateral, and a small-to-moderate third posterolateral branch.  The right coronary has an eccentric smooth 75% stenosis beginning about a centimeter after the origin of the vessel and prior to the acute marginal branch.  The remainder of the right coronary and its branches were without significant disease.
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DESCRIPTION: Selective coronary angiography, coronary angioplasty.  Acute non-ST-elevation MI.

cardiovascular / pulmonary, non-st-elevation mi, selective coronary angiography, coronary angioplasty, calcified plaque, coronary angiography, st elevation, stenosis, lad, coronary, selective, angiography, angioplasty, balloon, vessel, stent,

The situation involves the management of a 90-year-old patient with acute non-ST-elevation myocardial infarction (MI), who underwent coronary angioplasty. There were complications such as calcification preventing the advancement of a stent, decisions to avoid potentially risky procedures given the patient's advanced age and severe aortic stenosis, and the constant evaluation of hemodynamic status. These factors, combined with the patient's advanced age and pre-existing severe cardiac issues, make this a high-stakes medical situation, as the outcome could potentially be life-threatening.


Medical Specialty: Radiology
Sample Name: Conformal Simulation

CONFORMAL SIMULATION WITH COPLANAR BEAMS,This patient is undergoing a conformal simulation as the method to precisely define the area of disease which needs to be treated.  It allows us to highly focus the beam of radiation and shape the beam to the target volume, delivering a homogenous dosage through it while sparing the surrounding, more radiosensitive, normal tissues.  This will allow us to give the optimum chance of tumor control while minimizing the acute and long-term side effects.,A conformal simulation is a simulation which involves extended physician, therapist, and dosimetrist time and effort.  The patient is initially taken into a conventional simulator room, where appropriate markers are placed, and the patient is positioned and immobilized.  One then approximates the field sizes and arrangements (gantry angles, collimator angles, and number of fields).  Radiographs are taken, and these fields are marked on the patient's skin.  The patient is then transferred to the diagnostic facility and placed on a flat CT scan table.  Scans are then performed through the targeted area.  The CT scans are evaluated by the radiation oncologist, and the tumor volume, target volume, and critical structures are outlined on each slice of the CT scan.  The dosimetrist then evaluates each individual slice in the treatment planning computer with the appropriately marked structures.  This volume is then reconstructed in 3-dimensional space.  Utilizing the beam's-eye view features, the appropriate blocks are designed.  Multiplane computerized dosimetry is performed throughout the volume.  Field arrangements and blocking are modified as necessary to provide homogenous coverage of the target volume while minimizing the dose to normal structures.  Once all appropriate beam parameters and isodate distributions have been confirmed on the computer scan, each individual slice is then reviewed by the physician.  The beam's-eye view, block design, and appropriate volumes are also printed and reviewed by the physician.  Once these are approved, Cerrobend blocks will be custom fabricated.,If significant changes are made in the field arrangements from the original simulation, the patient is brought back to the simulator where the computer-designed fields are re-simulated.
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DESCRIPTION: Conformal simulation with coplanar beams.  This patient is undergoing a conformal simulation as the method to precisely define the area of disease which needs to be treated.

radiology, coplanar beams, ct scan, target volume, conformal simulation, beamsNOTE,: 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.,

Conformal simulations in radiology are critical for targeting tumors with radiation while minimizing exposure to healthy tissues. This process is essential for effective cancer treatment, affecting the patient's health outcomes. However, it doesn't involve immediate life-or-death stakes typical of emergency medical situations. The stakes are considered high due to the long-term implications of treatment success or failure, potential side effects, and the precision required in treatment planning.


Medical Specialty: Dermatology
Sample Name: Excision - Skin Neoplasm

PREOPERATIVE DIAGNOSES:,1.  Enlarging nevus of the left upper cheek.,2.  Enlarging nevus 0.5 x 1 cm, left lower cheek.,3.  Enlarging superficial nevus 0.5 x 1 cm, right nasal ala.,TITLE OF PROCEDURES:,1.  Excision of left upper cheek skin neoplasm 0.5 x 1 cm with two layer closure.,2.  Excision of the left lower cheek skin neoplasm 0.5 x 1 cm with a two layer plastic closure.,3.  Shave excision of the right nasal ala 0.5 x 1 cm skin neoplasm.,ANESTHESIA:  ,Local.  I used a total of 5 mL of 1% lidocaine with 1:100,000 epinephrine.,ESTIMATED BLOOD LOSS: , Less than 10 mL.,COMPLICATIONS:,  None.,PROCEDURE: , The patient was evaluated preop and noted to be in stable condition.  Chart and informed consent were all reviewed preop.  All risks, benefits, and alternatives regarding the procedure have been reviewed in detail with the patient.  Risks including but not limited to bleeding, infection, scarring, recurrence of the lesion, need for further procedures have been all reviewed.  Each of these lesions appears to be benign nevi; however, they have been increasing in size.  The lesions involving the left upper and lower cheek appear to be deep.  These required standard excision with the smaller lesion of the right nasal ala being more superficial and amenable to a superficial shave excision.  Each of these lesions was marked.  The skin was cleaned with a sterile alcohol swab.  Local anesthetic was infiltrated.  Sterile prep and drape were then performed.,Began first excision of the left upper cheek skin lesion.  This was excised with the 15-blade full thickness.  Once it was removed in its entirety, undermining was performed, and the wound was closed with 5-0 myochromic for the deep subcutaneous, 5-0 nylon interrupted for the skin.,The lesion of the lower cheek was removed in a similar manner.  Again, it was excised with a 15 blade with two layer plastic closure.  Both these lesions appear to be fairly deep nevi.,The right nasal ala nevus was superficially shaved using the radiofrequency wave unit.  Each of these lesions was sent as separate specimens.  The patient was discharged from my office in stable condition.  He had minimal blood loss.  The patient tolerated the procedure very well.  Postop care instructions were reviewed in detail.  We have scheduled a recheck in one week and we will make further recommendations at that time.
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DESCRIPTION: Excision of left upper cheek skin neoplasm and left lower cheek skin neoplasm with two-layer closure.  Shave excision of the right nasal ala skin neoplasm.

dermatology, enlarging nevus, nevus, skin neoplasm, nasal ala, cheek skin neoplasm, shave excision, superficial, lesions, neoplasm, excision, cheek

The procedure described involves the removal of potentially benign skin lesions, which have been increasing in size. These types of procedures in dermatology are generally routine, especially when the lesions are assessed pre-operatively to be benign. The use of local anesthesia, minor blood loss, and absence of complications suggest it is a low-risk procedure. While there is always some level of importance due to possible changes in diagnosis upon pathological examination, the stakes are not very high in this context unless further analysis suggests malignancy or other complications.


Medical Specialty: General Medicine
Sample Name: Normal ROS Template - 5

REVIEW OF SYSTEMS,GENERAL:  Negative weakness, negative fatigue, native malaise, negative chills, negative fever, negative night sweats, negative allergies.,INTEGUMENTARY:  Negative rash, negative jaundice.,HEMATOPOIETIC:  Negative bleeding, negative lymph node enlargement, negative bruisability.,NEUROLOGIC:  Negative headaches, negative syncope, negative seizures, negative weakness, negative tremor.  No history of strokes, no history of other neurologic conditions.,EYES:  Negative visual changes, negative diplopia, negative scotomata, negative impaired vision.,EARS:  Negative tinnitus, negative vertigo, negative hearing impairment.,NOSE AND THROAT:  Negative postnasal drip, negative sore throat.,CARDIOVASCULAR:  Negative chest pain, negative dyspnea on exertion, negative palpations, negative edema.  No history of heart attack, no history of arrhythmias, no history of hypertension.,RESPIRATORY:  No history of shortness of breath, no history of asthma, no history of chronic obstructive pulmonary disease, no history of obstructive sleep apnea.,GASTROINTESTINAL:  Negative dysphagia, negative nausea, negative vomiting, negative hematemesis, negative abdominal pain.,GENITOURINARY:  Negative frequency, negative urgency, negative dysuria, negative incontinence.  No history of STDs.  **No history of OB/GYN problems.,MUSCULOSKELETAL:  Negative myalgia, negative joint pain, negative stiffness, negative weakness, negative back pain.,PSYCHIATRIC:  See psychiatric evaluation.,ENDOCRINE:  No history of diabetes mellitus, no history of thyroid problems, no history of endocrinologic abnormalities.
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DESCRIPTION: Normal review of systems template.  Negative weakness, negative fatigue, native malaise, negative chills, negative fever, negative night sweats, negative allergies.

general medicine, respiratory, gastrointestinal, integumentary, hematopoietic, night sweats, negative allergies, negative weakness, neurologic, throat, weakness

The situation involves a generalized review of systems (ROS) template within a medical context, indicating that it is a routine part of clinical documentation and assessment. There are no immediate medical concerns or emergencies highlighted in this template, as everything listed is 'negative', suggesting normal or baseline findings. Therefore, it reflects a standard evaluation process without suggesting actively life-threatening conditions or high-risk scenarios.


Medical Specialty: Surgery
Sample Name: Aortobifemoral Bypass - 1

PREOPERATIVE DIAGNOSIS,1.  Aortoiliac occlusive disease bilaterally.,2.  Dementia.,POSTOPERATIVE DIAGNOSIS,1.  Aortoiliac occlusive disease bilaterally.,2.  Dementia.,OPERATION: , Aortobifemoral bypass surgery utilizing a bifurcated Hemashield graft.,ANESTHESIA:,  General endotracheal,ESTIMATED BLOOD LOSS: , 300 cc,INTRAVENOUS FLUIDS: , 1200 cc of crystalloid,URINE OUTPUT: , 250 cc,OPERATION IN DETAIL: , After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room and general endotracheal anesthesia was administered.  Note that previously the patient was found to have some baseline dementia, although slight.  The patient was seen and evaluated by the neurology team, who cleared the patient for surgery.  The patient was taken to the operating room and general endotracheal anesthesia was administered.  The abdomen was prepped and draped in the standard surgical fashion.  We first began our dissection by using a #10-blade scalpel to incise the skin over the femoral artery in the groin bilaterally.  Dissection was carried down to the level of the femoral vessels using Bovie electrocautery.  The common femoral, superficial femoral, and profunda femoris arteries were encircled and dissected out peripherally.  Vessel loops were placed around the aforementioned arteries.  After doing so, we turned our attention to beginning our abdominal dissection.  We used a #10-blade scalpel to make a midline laparotomy incision.  Dissection was carried down to the level of the fascia using Bovie electrocautery.  The abdomen was opened and an Omni retractor was positioned.  The aorta was dissected out in the abdomen.  The left femoral vein was identified.  There was a nicely clampable portion of aorta visible.  We, as mentioned, placed our Omni retractor and then turned our attention to performing our anastomosis.  Full-dose heparin was given.  Next, vascular clamps were applied to the iliac vessels as well as to the proximal aorta just below the renal vessels.  A #11-blade scalpel was used to make an arteriotomy in the aorta, which was lengthened both proximally and distally using Potts scissors.  We then beveled our proximal graft and constructed an end graft-to-side artery anastomosis using 3-0 Prolene in a running fashion.  Upon completion of our anastomosis, we flushed our graft and noted there was no evidence of a leak from the newly constructed anastomosis.  We then created our tunnels over the iliac vessels.  We pulled the distal limbs over our ABF graft into the groin.  We then proceeded to perform our right anastomosis first.  We applied vascular clamps on the proximal common femoral, profunda, and superficial femoral arteries.  We incised the common femoral artery and lengthened our arteriotomy in the vessel both proximally and distally.  We then footed the graft down onto the common femoral artery to the level of the SFA and constructed our anastomosis using 6-0 Prolene in a running fashion.  Upon completion of our anastomosis, we flushed the common femoral, SFA, and profunda femoris arteries.  We then removed our clamp.  We opened the limb more proximally in the abdomen on the right side.  We then turned our attention to the left side and similarly placed our vascular clamps.  We used a #11-blade scalpel to make an arteriotomy in the vessel.  We then lengthened our arteriotomy both proximally and distally again onto the SFA.  We constructed a footed end graft-to-side artery anastomosis using 6-0 Prolene in a running fashion.  Upon completion of our anastomosis, we opened our clamps.  There was no noticeable leak from the newly constructed anastomosis.  We checked our proximal graft to aortic anastomosis, which was noted to be in good condition.  We then gave full-dose protamine.  We closed the peritoneum over the graft with 4-0 Vicryl in a running fashion.  The abdomen was closed with #1 nylon in a running fashion.  The skin was closed with subcuticular 4-0 Monocryl in a running subcuticular fashion.  The instrument and sponge count was correct at end of case.  Patient tolerated the procedure well and was transferred to the intensive care unit in good condition.
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DESCRIPTION: Dementia and aortoiliac occlusive disease bilaterally.  Aortobifemoral bypass surgery utilizing a bifurcated Hemashield graft.

surgery, bifurcated, hemashield graft, aortoiliac occlusive disease, aortobifemoral bypass, vascular clamps, common femoral, graft, femoral, anastomosis, aortobifemoral, aortoiliac, proximal, arteriotomy, bypass, artery, endotracheal, vessels,

The situation involves an aortobifemoral bypass surgery, which is a complex and high-risk surgical procedure used to treat aortoiliac occlusive disease. The operation requires precision due to the critical nature of the affected arteries and the potential for complications such as bleeding or infection. Additionally, the patient has dementia, adding complexity to postoperative care and consent processes. These factors contribute to the high-stakes nature of the situation.


Medical Specialty: Hematology - Oncology
Sample Name: Neck Mass Biopsy

PREOPERATIVE DIAGNOSIS: , Malignant mass of the left neck.,POSTOPERATIVE DIAGNOSIS:,  Malignant mass of the left neck, squamous cell carcinoma.,PROCEDURES,1.  Left neck mass biopsy.,2.  Selective surgical neck dissection, left.,DESCRIPTION OF PROCEDURE:,  After obtaining an informed, the patient was taken to the operating room where a time-out process was followed.  Preoperative antibiotic was given and Dr. X proceeded to intubate the patient after a detailed anesthetic preparation that started in the Same Day Surgery and followed in the operating room.  Finally, a 5.5-French endotracheal tube was inserted and the patient was able to tolerate that and did have stable vital signs and a proper oxygenation.,Then, the patient was positioned with the neck slightly distended and turned toward the opposite side of the operation.  The neck was prepped and draped in the usual fashion.  I proceeded to mark the site of the mass and then also to mark the proposed site for the creation of a flap.  Then, I performed an extensive anesthetic block of the area.,Then, an incision was made along the area marked for development of the flap, but in a very limited extent, just to expose the cervical mass.  The cervical mass, which was about 4 cm in diameter and very firm and rubbery, was found lodged between the sternocleidomastoid muscle and the internal jugular vein in the area III of the neck.  A wedge sample was sent to Pathology for frozen section.  At the same time, we waited for the result and the initial report was not clear in the sense that a lot of lymphoepithelial reaction was seen.  Therefore, a larger sample was sent to Pathology and at that particular time, the fresh frozen was reported as having squamous elements.  This was not totally clear in my mind and therefore I proceeded to excise the full mass, which luckily was not attached to any structures except in the very deep surface.  There, there were some attachments to branches of the external carotid artery, which had to be suture ligated.  At any rate, the whole specimen was to the lab and finally the diagnosis was that of a metastatic squamous cell carcinoma.,With that information in hand, we proceeded to continue with a neck dissection and proceeded to make an incision along the previously marked sites of the flap, which basically involved a reverse U shape on the left neck.  This worked out quite nicely.  The external jugular vein was out of the way, so initially we did not deal with it.  We proceeded to tackle the area III and extended into II-A.  When we excised the mass, the upper end was in intimate relationship with the parotid gland, which was relatively large in this patient, but it looked normal otherwise.  Also, I felt that the submaxillary gland was enlarged.  At any rate, we decided to clean up the areas III and IV and a few nodes from II-A that were removed, and then we went into the posterior triangle where we identified the spinal accessory nerve, which we protected, actually did not even dissect close to it.,The same nerve had been already identified anterior to the internal jugular vein, very proximally behind the digastric and the sternocleidomastoid muscle.  At any rate, there were large nodes in the posterior triangle, in areas V-A and V-B, which were excised and sent to Pathology for examination.  Also, there was a remnant of a capsule of the main mass that we proceeded to excise and sent to Pathology as an extra specimen.  Hemostasis was revised and found to be adequate.  The flaps had been protected by folding it to the chest and protected by wet sponges on both sides of the flap.  The flap was replaced in its position.  A soft Jackson-Pratt catheter was left in the area, and then we proceeded to approximate the flap with a number of subcutaneous sutures of Vicryl and then running sutures of subcuticular Monocryl to the skin.  I would like to mention that also the facial vein was excised and the external jugular vein was ligated.  It was in very lateral location and it was on the site of the drain, so we ligated that but did not excise it.  A pressure dressing was applied.,The patient tolerated the procedure well.  Estimated blood loss was no more than 100 mL.  The patient was extubated in the operating room and sent for recovery.
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DESCRIPTION: Malignant mass of the left neck, squamous cell carcinoma.  Left neck mass biopsy and selective surgical neck dissection, left.

hematology - oncology, neck mass biopsy, surgical neck dissection, internal jugular vein, external jugular vein, squamous cell carcinoma, neck mass, malignant mass, neck dissection, mass, neck, wedge, vein,

This situation involves a patient undergoing a biopsy and neck dissection due to a malignant neck mass diagnosed as squamous cell carcinoma. The stakes are high because the outcome could significantly affect the patient's health and treatment options. Cancer diagnoses and surgical procedures like these often carry significant risks and implications for treatment and prognosis.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Lobectomy & Lymph Node Dissection

OPERATION,1.  Right upper lung lobectomy.,2.  Mediastinal lymph node dissection.,ANESTHESIA,1.  General endotracheal anesthesia with dual-lumen tube.,2.  Thoracic epidural.,OPERATIVE PROCEDURE IN DETAIL: , After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room, and general endotracheal anesthesia was administered with a dual-lumen tube.  Next, the patient was placed in the left lateral decubitus position, and his right chest was prepped and draped in the standard surgical fashion.  We used a #10-blade scalpel to make an incision in the skin approximately 1 fingerbreadth below the angle of the scapula.  Dissection was carried down in a muscle-sparing fashion using Bovie electrocautery.  The 5th rib was counted, and the 6th interspace was entered.  The lung was deflated.  We identified the major fissure.  We then began by freeing up the inferior pulmonary ligament, which was done with Bovie electrocautery.  Next, we used Bovie electrocautery to dissect the pleura off the lung.  The pulmonary artery branches to the right upper lobe of the lung were identified.  Of note was the fact that there was a visible, approximately 4 x 4-cm mass in the right upper lobe of the lung without any other metastatic disease palpable.  As mentioned, a combination of Bovie electrocautery and sharp dissection was used to identify the pulmonary artery branches to the right upper lobe of the lung.  Next, we began by ligating the pulmonary artery branches of the right upper lobe of the lung.  This was done with suture ligature in combination with clips.  After taking the pulmonary artery branches of the right upper lobe of the lung, we used a combination of blunt dissection and sharp dissection with Metzenbaum scissors to separate out the pulmonary vein branch of the right upper lobe of the lung.  This likewise was ligated with a 0 silk.  It was stick-tied with a 2-0 silk.  It was then divided.  Next we dissected out the bronchial branch to the right upper lobe of the lung.  A curved Glover was placed around the bronchus.  Next a TA-30 stapler was fired across the bronchus.  The bronchus was divided with a #10-blade scalpel.  The specimen was handed off.  We next performed a mediastinal lymph node dissection.  Clips were applied to the base of the feeding vessels to the lymph nodes.  We inspected for any signs of bleeding.  There was minimal bleeding.  We placed a #32-French anterior chest tube, and a #32-French posterior chest tube.  The rib space was closed with #2 Vicryl in an interrupted figure-of-eight fashion.  A flat Jackson-Pratt drain, #10 in size, was placed in the subcutaneous flap.  The muscle layer was closed with a combination of 2-0 Vicryl followed by 2-0 Vicryl, followed by 4-0 Monocryl in a running subcuticular fashion.  Sterile dressing was applied.  The instrument and sponge count was correct at the end of the case.  The patient tolerated the procedure well and was transferred to the PACU in good condition.
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DESCRIPTION: Right upper lung lobectomy.  Mediastinal lymph node dissection

cardiovascular / pulmonary, mediastinal, thoracic, epidural, lymph node dissection, lymph node, artery branches, lobectomy, lung, anesthesia, bovie, electrocautery, lymph, pulmonary, branches

A lung lobectomy with mediastinal lymph node dissection is a major surgical procedure often performed for conditions like lung cancer. The stakes are high because it involves the removal of a part of the lung and associated lymph nodes, which are critical structures. The detailed surgical procedure indicates that it requires precise and complex maneuvers to ensure both the successful removal of the diseased tissue and the preservation of the patient's respiratory function. Any complications such as excessive bleeding, damage to surrounding tissues, or anesthesia risks can have serious consequences for the patient, including life-threatening outcomes.


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

OPERATION PERFORMED: , Cervical epidural steroid injection C7-T1.,ANESTHESIA:,  Local and Versed 2 mg IV.,COMPLICATIONS:  ,None.,DESCRIPTION OF PROCEDURE:  ,The patient was placed in the seated position with the neck flexed the forehead was placed on a cervical rest.  The head and cervical spine were restrained.  The patient was monitored with a blood pressure cuff, EKG and pulse oximetry.  The skin was prepped and draped in sterile classical fashion.  Excess cleansing solution was removed from the skin.  Local anesthesia was injected at C7-T1.  An 18-gauge Tuohy needle was then placed in the epidural space with loss of resistance technique and a saline-filled syringe utilizing a midline intralaminar approach.,Once the epidural space was identified, a negative aspiration for heme or CSF was done.  This was followed by the injection of 6 cc of saline mixed with methyl prednisolone acetate 120 mg in aliquots of 2 cc.  Negative aspirations were done prior to each injection.  The needle was cleared with saline prior to its withdrawal.  The patient tolerated the procedure well without any apparent difficulties or complications.
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DESCRIPTION: Cervical epidural steroid injection C7-T1.  An 18-gauge Tuohy needle was then placed in the epidural space with loss of resistance technique and a saline-filled syringe utilizing a midline intralaminar approach.

pain management, tuohy needle, cleansing solution, epidural space, loss of resistance, cervical epidural steroid injection, resistance technique, steroid injection, injection, intralaminar, steroid, epidural,

The procedure described is a cervical epidural steroid injection, which is a common and generally safe procedure used to relieve neck pain. While it involves inserting a needle near the spinal cord, which could pose risks—like infection, bleeding, or nerve damage—such complications are rare when performed by trained professionals. The operation appears to have been completed without complications, and the situation does not involve any emergencies or high-risk conditions. Therefore, the situation is not of particularly high-stakes.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Heart Catheterization, Ventriculography, & Angiography - 9

PROCEDURE:,  Left heart catheterization, left ventriculography, selective coronary angiography.,INDICATION: , This lady with a previous left internal mammary graft to left anterior descending, saphenous vein graft to obtuse margin branch, saphenous vein graft to the diagonal branch, and saphenous vein graft to the right coronary artery presented with recurrent difficulties with breathing.  This was felt to be related largely to chronic obstructive lung disease.  She had dynamic T-wave changes in precordial leads.  Cardiac enzymes were indeterminate.  She was evaluated by Dr. X and given her previous history and multiple risk factors it was elected to proceed with cardiac catheterization and coronary angiography.,Risks of the procedure including risks of conscious sedation, death, cerebrovascular accident, dye reaction, need for emergency surgery, vascular access injury and/or infection, and risks of cath-based interventions were discussed in detail.  The patient understood and agreed to proceed.,DESCRIPTION OF THE PROCEDURE: , The patient was brought to the cardiac catheterization laboratory.  Under Versed and fentanyl sedation, the right groin was sterilely prepped and draped.  Local anesthesia was obtained with 2% Xylocaine.  The right femoral artery was entered using modified Seldinger technique and a 4-French introducer sheath placed in that vessel.  Through the indwelling femoral arterial sheath, a JL4 4-French catheter was advanced over the wire to the ascending aorta, appropriately aspirated and flushed.  Ascending aortic root pressures obtained.  This catheter was utilized in an attempt to cannulate the left coronary ostium.  This catheter was too small, was exchanged for a JL5 4-French catheter, which was advanced over the wire to the ascending aorta, the cath appropriately aspirated and flushed, and advanced to left coronary ostium and multiple views of left coronary artery obtained.,This catheter was then exchanged for a 4-French right coronary catheter, which was advanced over the wire to the ascending aorta.  The catheter appropriately aspirated and flushed.  The catheter was advanced in the right coronary artery.  Multiple views of that vessel were obtained.  The catheter was then sequentially advanced to the saphenous vein graft to the diagonal branch, saphenous vein graft to the obtuse marginal branch, and left internal mammary artery, left anterior descending coronary artery, and multiple views of those vessels were obtained.  This catheter was then exchanged for a 4-French pigtail catheter, which was advanced over the wire to the ascending aorta.  The catheter was appropriately aspirated and flushed and advanced to left ventricle, baseline left ventricular pressures obtained.,Following this, left ventriculography was performed in a 30-degree RAO projection using 30 mL of contrast injected over 3 seconds.  Post left ventriculography pressures were then obtained as was a pullback pressure across the aortic valve.  Videotapes were then reviewed.  It was elected to terminate the procedure at that point in time.,The vascular sheath was removed and manual compression carried out.  Excellent hemostasis was obtained.  The patient tolerated the procedure without complication.,RESULTS OF PROCEDURE,1.  ,HEMODYNAMICS:,  Left ventricular end-diastolic filling pressure was 24.  There was no gradient across the aortic valve.,2.  ,LEFT VENTRICULOGRAPHY: , Left ventriculography demonstrated well-preserved left ventricular systolic function.  Mild inferobasilar hypokinesis was noted.  No significant mitral regurgitation noted.  Ejection fraction was estimated at 60%.,3.  ,CORONARY ARTERIOGRAPHY,A.  ,LEFT MAIN CORONARY: , The left main coronary was patent.,B.  ,LEFT ANTERIOR DESCENDING CORONARY ARTERY:,  Left anterior descending coronary was occluded shortly after a very small first septal perforator was given.,C.  ,CIRCUMFLEX CORONARY ARTERY:,  Circumflex coronary artery was occluded at its origin.,D.  ,RIGHT CORONARY ARTERY,.  Right coronary artery was occluded in its mid portion.,4.  ,SAPHENOUS VEIN GRAFT ANGIOGRAPHY,A.  ,SAPHENOUS VEIN GRAFT TO THE DIAGONAL BRANCH: , The saphenous vein graft to diagonal branch was widely patent at its origin and insertion sites.  Excellent flow was noted in the diagonal system with some retrograde flow.,B.  There was retrograde flow as well in the left anterior descending system.,C.  ,SAPHENOUS VEIN GRAFT TO THE OBTUSE MARGINAL SYSTEM:,  Saphenous vein graft to the obtuse marginal system was widely patent at its origin and insertion sites.  There was no graft disease noted.  Excellent flow was noted in the bifurcating marginal system.,D.  ,SAPHENOUS VEIN GRAFT TO RIGHT CORONARY ARTERY:,  Saphenous vein graft to right coronary was widely patent with no graft disease.  Origin and insertion sites were free of disease.  Distal flow in the graft to the posterior descending was normal.,5.  ,LEFT INTERNAL MAMMARY ARTERY ANGIOGRAPHY: , Left internal mammary artery angiography demonstrated a widely patent left internal mammary at its origin and insertion sites.  There was no focal disease noted, inserted into the mid-to-distal LAD which was a small-caliber vessel.  Retrograde filling of a small septal system was noted.,SUMMARY OF RESULTS,1.  Elevated left ventricular end-diastolic filling pressure with normal left ventricular systolic function and mild hypokinesis of inferobasilar segment.
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DESCRIPTION: Left heart catheterization, left ventriculography, selective coronary angiography.

The description of the medical procedure involves a patient undergoing a left heart catheterization, ventriculography, and selective coronary angiography. These are invasive and high-risk procedures, particularly given the patient's complex clinical background, including previous graft surgeries and recurrent breathing issues. Risks highlighted include death, cerebrovascular accident, dye reaction, and potential need for emergency surgery. The stakes are high because the procedure directly pertains to the cardiovascular health of the patient and involves critical decision-making that could impact their survival and quality of life.


Medical Specialty: Orthopedic
Sample Name: Anterior Cervical Discectomy & Osteophytectomy

PREOPERATIVE DIAGNOSES,1.  Cervical radiculopathy, C5-C6 and C6-C7.,2.  Symptomatic cervical spondylosis, C5-C6 and C6-C7.,3.  Symptomatic cervical stenosis, C5-C6 and C6-C7.,4.  Symptomatic cervical disc herniations, C5-C6 and C6-C7.,POSTOPERATIVE DIAGNOSES,1.  Cervical radiculopathy, C5-C6 and C6-C7.,2.  Symptomatic cervical spondylosis, C5-C6 and C6-C7.,3.  Symptomatic cervical stenosis, C5-C6 and C6-C7.,4.  Symptomatic cervical disc herniations, C5-C6 and C6-C7.,OPERATIVE PROCEDURE,1.  CPT code 63075:  Anterior cervical discectomy and osteophytectomy, C5-C6.,2.  CPT code 63076:  Anterior cervical discectomy and osteophytectomy, C6-C7, additional level.,3.  CPT code 22851:  Application of prosthetic interbody fusion device, C5-C6.,4.  CPT code 22851-59:  Application of prosthetic interbody fusion device, C6-C7, additional level.,5.  CPT code 22554-51:  Anterior cervical interbody arthrodesis, C5-C6.,6.  CPT code 22585:  Anterior cervical interbody arthrodesis, C6-C7, additional level.,7.  CPT code 22845:  Anterior cervical instrumentation, C5-C7.,ANESTHESIA:,  General endotracheal.,ESTIMATED BLOOD LOSS:  ,Negligible.,DRAINS: , Small suction drain in the cervical wound.,COMPLICATIONS:,  None.,PROCEDURE IN DETAIL:,  The patient was given intravenous antibiotic prophylaxis and thigh-high TED hoses were placed on the lower extremities while in the preanesthesia holding area.  The patient was transported to the operative suite and on to the operative table in the supine position.  General endotracheal anesthesia was induced.  The head was placed on a well-padded head holder.  The eyes and face were protected from pressure.  A well-padded roll was placed beneath the neck and shoulders to help preserve the cervical lordosis.  The arms were tucked and draped to the sides.  All bony prominences were well padded.  An x-ray was taken to confirm the correct level of the skin incision.  The anterior neck was then prepped and draped in the usual sterile fashion.,A straight transverse skin incision over the left side of the anterior neck was made and carried down sharply through the skin and subcutaneous tissues to the level of the platysma muscle, which was divided transversely using the electrocautery.  The superficial and deep layers of the deep cervical fascia were divided.  The midline structures were reflected to the right side.  Care was taken during the dissection to avoid injury to the recurrent laryngeal nerve and the usual anatomical location of that nerve was protected.  The carotid sheath was palpated and protected laterally.  An x-ray was taken to confirm the level of C5-C6 and C6-C7.,The longus colli muscle was dissected free bilaterally from C5 to C7 using blunt dissection.  Hemostasis was obtained using the electrocautery.  The blades of the cervical retractor were placed deep to the longus colli muscles bilaterally.  At C5-C6, the anterior longitudinal ligament was divided transversely.  Straight pituitary rongeurs and a curette were used to remove the contents of the disc space.  All cartilages were scraped off the inferior endplate of C5 and from the superior endplate of C6.  The disc resection was carried posteriorly to the posterior longitudinal ligament and laterally to the uncovertebral joints.  The posterior longitudinal ligament was resected using a 1 mm Kerrison rongeur.  Beginning in the midline and extending into both neural foramen, posterior osteophytes were removed using a 1 m and a 2 mm Kerrison rongeurs.  The patient was noted to have significant bony spondylosis causing canal and foraminal stenosis as well as a degenerative and protruding disc in agreement with preoperative diagnostic imaging studies.  Following completion of the discectomy and osteophytectomy, a blunt nerve hook was passed into the canal superiorly and inferiorly as well as in the both neural foramen to make sure that there were no extruded disc fragments and to make sure the bony decompression was complete.  A portion of the uncovertebral joint was resected bilaterally for additional nerve root decompression.  Both nerve roots were visualized and noted to be free of encroachment.  The same procedure was then carried out at C6-C7 with similar findings.  The only difference in the findings was that at C6-C7 on the left side, the patient was found to have an extruded disc fragment in the canal and extending into the left side neural foramen causing significant cord and nerve root encroachment.,In preparation for the arthrodesis, the endplates of C5, C6, and C7 were burred in a parallel fashion down to the level of bleeding bone using a high-speed cutting bur with irrigant solution for cooling.  The disc spaces were then measured to the nearest millimeter.  Attention was then turned toward preparation of the structural allograft, which consisted of two pieces of pre-machined corticocancellous bone.  The grafts were further shaped to fit the disc spaces exactly in a press-fit manner with approximately 1.5 mm of distraction at each disc space.  The grafts were shaped to be slightly lordotic to help preserve the cervical lordosis.  The grafts were impacted into the disc spaces.  There was complete bony apposition between the ends of the bone grafts and the vertebral bodies of C5, C6, and C7.  A blunt nerve hook was passed posterior to each bone graft to make sure that the bone grafts were in good position.  Anterior osteophytes were removed using a high-speed cutting bur with irrigant solution for cooling.  An appropriate length Synthes cervical plate was selected and bent slightly to conform to the patient's cervical lordosis.  The plate was held in the midline with provided instrumentation while a temporary fixation screw was applied at C6.  Screw holes were then drilled using the provided drill and drill guide taking care to avoid injury to neurovascular structures.  The plate was then rigidly fixed to the anterior spine using 14-mm cancellous screws followed by locking setscrews added to the head of each screw to prevent postoperative loosening of the plate and/or screws.,An x-ray was taken, which confirmed satisfactory postioning of the plate, screws, and bone grafts.,Blood loss was minimal.  The wound was irrigated with irrigant solution containing antibiotics.  The wound was inspected and judged to be dry.  The wound was closed over a suction drain placed in the deepest portion of the wound by reapproximating the platysma muscle with #4-0 Vicryl running suture, the subdermal and subcuticular layers with #4-0 Monocryl interrupted sutures, and the skin with Steri-Strips.  The sponge and needle count were correct.  A sterile dressing was applied to the wound.  The neck was placed in a cervical orthosis.  The patient tolerated the procedure and was transferred to the recovery room in stable condition.
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DESCRIPTION: Anterior cervical discectomy and osteophytectomy.  Application of prosthetic interbody fusion device.  Anterior cervical interbody arthrodesis.  Anterior cervical instrumentation

The described procedure, an anterior cervical discectomy with osteophytectomy, is a significant spinal surgery involving the cervical spine (neck area). It addresses serious conditions such as cervical radiculopathy, cervical spondylosis, stenosis, and disc herniations, which can cause severe symptoms, including pain, numbness, and weakness. The surgery aims to decompress the nerve roots and stabilize the spine, which are critical to the patient's quality of life and function. While the document notes that there were no complications and the estimated blood loss was negligible, thereby reducing some immediate risks, spinal surgeries inherently carry high stakes due to potential complications such as nerve damage, infection, or impacts on spinal stability. Additionally, the procedure involves handling critical neurovascular structures, adding to its complexity. These factors contribute to its high-stakes nature.


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

Medical Specialty: Neurosurgery
Sample Name: Pituitary Tumor Resection

TITLE OF OPERATION: , Transnasal transsphenoidal approach in resection of pituitary tumor.,INDICATION FOR SURGERY: , The patient is a 17-year-old girl who presented with headaches and was found to have a prolactin of 200 and pituitary tumor.  She was started on Dostinex with increasing dosages.  The most recent MRI demonstrated an increased growth with hemorrhage.  This was then discontinued.  Most recent prolactin was at 70, although normalized, the recommendation was surgical resection given the size of the sellar lesion.  All the risks, benefits, and alternatives were explained in great detail via translator.,PREOP DIAGNOSIS: , Pituitary tumor.,POSTOP DIAGNOSIS: , Pituitary tumor.,PROCEDURE DETAIL:  ,The patient brought to the operating room, positioned on the horseshoe headrest in a neutral position supine.  The fluoroscope was then positioned.  The approach will be dictated by Dr. X. Once the operating microscope and the endoscope were then used to approach it through transnasal, this was complicated and complex secondary to the drilling within the sinus.  Once this was ensured, the tumor was identified, separated from the pituitary gland, it was isolated and then removed.  It appeared to be hemorrhagic and a necrotic pituitary, several sections were sent.  Once this was ensured and completed and hemostasis obtained, the wound was irrigated.  There might have been a small CSF leak with Valsalva, so the recommendation was for a reconstruction, Dr. X will dictate.  The fat graft was harvested from the left lower quadrant and closed primarily, this was soaked in fat and used to close the closure.  All sponge and needle counts were correct.  The patient was extubated and transported to the recovery room in stable condition.  Blood loss was minimal.
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DESCRIPTION: Transnasal transsphenoidal approach in resection of pituitary tumor.   The patient is a 17-year-old girl who presented with headaches and was found to have a prolactin of 200 and pituitary tumor.

neurosurgery, transnasal transsphenoidal approach, resection, pituitary tumor, transsphenoidal, transnasal, prolactin, tumor, pituitary,

The operation described is a neurosurgical procedure involving the resection of a pituitary tumor through a transnasal transsphenoidal approach. Such surgeries inherently carry significant risks, including potential damage to surrounding brain structures, risk of cerebrospinal fluid (CSF) leaks, and other intraoperative complications. Additionally, the patient's age and the presence of hemorrhage in the tumor add complexity and urgency, as it can affect neurological and endocrine function if not adequately addressed. The stakes are high due to the potential for postoperative complications affecting the patient's quality of life and the precision required during the surgery.


Medical Specialty: Surgery
Sample Name: Double Lumen Port Inserstion

PREOPERATIVE DIAGNOSIS:,  Metastatic glossal carcinoma, needing chemotherapy and a port.,POSTOPERATIVE DIAGNOSIS: , Metastatic glossal carcinoma, needing chemotherapy and a port.,PROCEDURES,1.  Open exploration of the left subclavian/axillary vein.,2.  Insertion of a double lumen port through the left femoral vein, radiological guidance.,DESCRIPTION OF PROCEDURE: , After obtaining the informed consent, the patient was electively taken to the operating room, where he underwent a general anesthetic through his tracheostomy.  The left deltopectoral and cervical areas were prepped and draped in the usual fashion.  Local anesthetic was infiltrated in the area.  There was some evidence that surgical procedure had happened in the area nearby and also there was collateral venous circulation under the skin, which made us suspicious that may be __________, but at any rate I tried to cannulate it subcutaneously and I was unsuccessful.  Therefore, I proceeded to make an incision and was able to isolate the vein, which would look very sclerotic.  I tried to cannulate it, but I could not advance the wire.,At that moment, I decided that there was no way we are going to put a port though that area.  I packed the incision and we prepped and redraped the patient including both groins.  Local anesthetic was infiltrated and then the left femoral vein was percutaneously cannulated without any difficulty.  The introducer was placed and then a wire and then the catheter of the double lumen port, which had been trimmed to position it near the heart.  It was done with radiological guidance.  Again, I was able to position the catheter in the junction of inferior vena cava and right atrium.  The catheter was looked upwards and the double lumen port was inserted subcutaneously towards the iliac area.  The port had been aspirated satisfactorily and irrigated with heparin solution.  The drain incision was closed in layers including subcuticular suture with Monocryl.  Then, we went up to the left shoulder and closed that incision in layers.  Dressings were applied.,The patient tolerated the procedure well and was sent back to recovery room in satisfactory condition.
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DESCRIPTION: Insertion of a double lumen port through the left femoral vein, radiological guidance.  Open exploration of the left subclavian and axillary vein.  Metastatic glossal carcinoma, needing chemotherapy and a port.

surgery, axillary, vein, subclavian, double lumen port, femoral vein, radiological guidance, glossal carcinoma, port, inserstion, femoral, radiological, metastatic, carcinoma, chemotherapy, anesthetic, catheter,

The procedure described involves the insertion of a double lumen port for chemotherapy in a patient with metastatic glossal carcinoma. The nature of the surgery carries significant risks due to the medical condition (cancer) and the need for chemotherapy access. Invasive procedures in patients with cancer, particularly when involving veins and requiring radiological guidance, imply a higher degree of concern for potential complications, such as infection or complications from anesthesia. Additionally, the procedure was complicated by the inability to use the initial vein, requiring adjustment and alternative access routes, which increases the complexity and stakes of the operation. Despite these challenges, the patient tolerated the procedure well and recovered satisfactorily, but the stakes are elevated due to the patient's overall health context and the critical need for chemotherapy treatment.


Medical Specialty: Urology
Sample Name: Testicular Pain

CHIEF COMPLAINT: , Testicular pain.,HISTORY OF PRESENT ILLNESS:,  The patient is a 4-year-old boy with a history of abrupt onset of left testicular pain at 11:30 this morning.  He was unable to walk and would not stand upright, and had fairly significant discomfort, so the parents checked his panel because of it.  Because of this, they took him to Emergency Department, at which time, he had no swelling noted initially, but very painful.  He had no voiding or stooling problems.  No nausea, vomiting or fever.  Family denies trauma or dysuria.  At that time, he was going to get an ultrasound done, but the mother said that all of sudden the patient stated the pain had resolved.  He has had hot chocolate this morning at 10:30 in the morning and water around 2:30 in the morning.  He has not had any pain since but states that he has had pain in the past, not as long and states there was a twisting sensation.  He has no recent cold or flu, although he had rhinorrhea about 3 weeks ago.  He is on no medications and he is here for evaluation.,PAST MEDICAL HISTORY:,  The patient has no known allergies.  He is term delivery via spontaneous vaginal delivery.  He has had no problems or hospitalizations with circumcision.,PAST SURGICAL HISTORY: , He has had no previous surgeries.,REVIEW OF SYSTEMS:,  All 14-point review of systems were negative except for the above left testicular pain and the history of possible upper respiratory infection about 2 to 3 weeks ago.,IMMUNIZATIONS: , Up-to-date.,FAMILY HISTORY: , The patient lives at home with both parents who are Spanish speaking.  He is not in school.,MEDICATIONS:,  He is on no medications.,PHYSICAL EXAMINATION:,VITAL SIGNS:  On physical exam, weight is 15.9 kg.,GENERAL:  The patient is a cooperative little boy.,HEENT:  Normal head and neck exam.  No oral or nasal discharge.,NECK:  Without masses.,CHEST:  Without masses.,LUNGS:  Clear.,CARDIAC:  Without murmurs or gallops.,ABDOMEN:  Soft.  No masses or tenderness.  His scrotum did not have any swelling at the present time.  There was only minimal discomfort with palpation at the left inguinal area, but no masses were noted.  No palpable nodules such as appendix testis and no swelling was noted and he had mild epididymal swelling only.  His left testis was slightly harder than the right, but this was not very significant.,EXTREMITIES:  He had full range of motion in all 4 extremities.,SKIN:  Warm, pink, and dry.,NEUROLOGIC:  Grossly intact.,LABORATORY DATA: , Ultrasound was obtained today showing no blood flow or poor blood flow on the left except for increased blood flow to the epididymis on the study done at about 1330 hours, and second one done around 1630 hours was normal flow, possible increased flow on the left.  This is personally reviewed by me.  The right was normal.  No masses were appreciated.  There was some mild change in echotexture on the left on the initial study, which had apparently resolved on the second, but may be due to the technical aspects of the study.,ASSESSMENT/PLAN: , The patient has a possibly torsion detorsion versus other acute testicular problem.  If the patient has indeed testicular torsion, there is an increased possibility that it may reoccur again, actually within the first 24 to 36 hours and as such is recommended doing a left scrotal exploration with possible detorsion of left testis, possible orchiectomy if the testis is markedly abnormal or nonviable, which probably is not the case, and bilateral testes fixation if the torsion is found.  I discussed the pre and postsurgical care with the parents.  Procedure itself with potential complications, risks, benefits, and alternatives of surgery including that the torsion could occur again, although it is less likely after the surgical fixation procedure.  The parents understand and wished to proceed.  We will schedule this later today emergently.
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DESCRIPTION: The patient has a possibly torsion detorsion versus other acute testicular problem.

The situation involves a young child with suspected testicular torsion, a medical emergency due to the risk of losing the testicle if not promptly addressed. The need for urgent surgical intervention indicates high stakes, as delays can lead to irreversible damage or loss of the testicle. The decision to perform surgery emergently demonstrates the critical nature of the condition.


Medical Specialty: Psychiatry / Psychology
Sample Name: Falls - Discharge Summary

CHIEF COMPLAINT:,  Falls at home.,HISTORY OF PRESENT ILLNESS:,  The patient is an 82-year-old female who fell at home and presented to the emergency room with increased anxiety.  Family members who are present state that the patient had been increasingly anxious and freely admitted that she was depressed at home.  They noted that she frequently came to the emergency room for "attention."  The patient denied any chest pain or pressure and no change to exercise tolerance.  The patient denied any loss of consciousness or incontinence.  She denies any seizure activity.  She states that she "tripped" at home.  Family states she frequently takes Darvocet for her anxiety and that makes her feel better, but they are afraid she is self medicating.  They stated that she has numerous medications at home, but they were not sure if she was taking them.  The patient been getting along for a number of years and has been doing well, but recently has been noting some decline primarily with regards to her depression.  The patient denied SI or HI.,PHYSICAL EXAMINATION:,GENERAL:  The patient is pleasant 82-year-old female in no acute distress.,VITAL SIGNS:  Stable.,HEENT:  Negative.,NECK:  Supple.  Carotid upstrokes are 2+.,LUNGS:  Clear.,HEART:  Normal S1 and S2.  No gallops.  Rate is regular.,ABDOMEN:  Soft.  Positive bowel sounds.  Nontender.,EXTREMITIES:  No edema.  There is some ecchymosis noted to the left great toe.  The area is tender; however, metatarsal is nontender.,NEUROLOGICAL:  Grossly nonfocal.,HOSPITAL COURSE: , A psychiatric evaluation was obtained due to the patient's increased depression and anxiety.  Continue Paxil and Xanax use was recommended.  The patient remained medically stable during her hospital stay and arrangements were made for discharge to a rehabilitation program given her recent falls.,DISCHARGE DIAGNOSES:,1.  Falls ,2.  Anxiety and depression.,3.  Hypertension.,4.  Hypercholesterolemia.,5.  Coronary artery disease.,6.  Osteoarthritis.,7.  Chronic obstructive pulmonary disease.,8.  Hypothyroidism.,CONDITION UPON DISCHARGE: , Stable.,DISCHARGE MEDICATIONS: , Tylenol 650 mg q.6h. p.r.n., Xanax 0.5 q.4h. p.r.n., Lasix 80 mg daily, Isordil 10 mg t.i.d., KCl 20 mEq b.i.d., lactulose 10 g daily, Cozaar 50 mg daily, Synthroid 75 mcg daily, Singulair 10 mg daily, Lumigan one drop both eyes at bed time, NitroQuick p.r.n., Pravachol 20 mg daily, Feldene 20 mg daily, Paxil 20 mg daily, Minipress 2 mg daily, Provera p.r.n., Advair 250/50 one puff b.i.d., Senokot one tablet b.i.d., Timoptic one drop OU daily, and verapamil 80 mg b.i.d.,ALLERGIES: , None.,ACTIVITY: , Per PT.,FOLLOW-UP: , The patient discharged to a skilled nursing facility for further rehabilitation.
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DESCRIPTION: Falls at home.  Anxiety and depression.  The patient had been increasingly anxious and freely admitted that she was depressed at home.

This situation involves an elderly patient who has experienced falls at home, coupled with increased anxiety and depression. The patient has multiple chronic health conditions, takes numerous medications, and there are concerns about self-medication with Darvocet. While the patient is medically stable upon discharge, the complex interplay of psychiatric issues, potential medication mismanagement, and rehabilitation needs signify high stakes. The risks include potential for future falls, worsening mental health, improper medication use, and insufficient home support. The involvement of a rehabilitation program post-discharge and the coordination of care with psychiatric evaluation highlight that this is a higher stakes situation, primarily due to the patient's vulnerability and the complexity of managing her health needs effectively.


Medical Specialty: ENT - Otolaryngology
Sample Name: Laryngectomy & Thyroid Lobectomy

TITLE OF OPERATION:,  Total laryngectomy, right level 2, 3, 4 neck dissection, tracheoesophageal puncture, cricopharyngeal myotomy, right thyroid lobectomy.,INDICATION FOR SURGERY: , A 58-year-old gentleman who has had a history of a T3 squamous cell carcinoma of his glottic larynx having elected to undergo a laser excision procedure in late 06/07.  Subsequently, biopsy confirmed tumor persistence in the right glottic region.  Risks, benefits, and alternatives of the surgical intervention versus possibility of chemoradiation therapy were discussed with the patient in detail.  Also concerned for a CT scan finding of possible cartilaginous invasion at the cricoid level.  The patient understood the issues regarding surgical intervention and wished to undergo a surgical intervention despite a clear understanding of risks, benefits, and alternatives.  He was accompanied by his wife and daughter.  Risks included, but were not limited to anesthesia, bleeding, infection, injury of the nerves including lower lip weakness, tongue weakness, tongue numbness, shoulder weakness, need for physical therapy, possibility of total laryngectomy, possibility of inability to speak or swallow, difficulty eating, wound care issues, failure to heal, need for additional treatment, and the patient understood all of these issues and they wished to proceed.,PREOP DIAGNOSIS: , Squamous cell carcinoma of the larynx.,POSTOP DIAGNOSIS: , Squamous cell carcinoma of the larynx.,PROCEDURE DETAIL: , After identifying the patient, the patient was placed supine on the operating room table.  After the establishment of the general anesthesia via oral endotracheal intubation, the patient had his eyes protected with Tegaderm.  A #6 endotracheal tube was placed initially.  Direct laryngoscopy was performed with a Lindholm laryngoscope.  A 0-degree endoscope was used to take pictures of what was apparently a recurrence of tumor along the right true vocal fold extending into the anterior arytenoid area and extending about 1 cm below into the subglottis.  Subsequently, a decision was then made to go ahead and perform the surgical intervention.  A hemi-apron incision was employed, and 1% lidocaine with 1:100,000 epinephrine was injected.  A shoulder roll was applied after the patient was prepped and draped in a sterile fashion.  Subsequently, a hemi-apron incision was performed.  Subplatysmal flaps were raised at the hyoid bone into the clavicle.  Attention was then turned to the right side, where a level 2, 3, 4 neck dissection was performed.  Submandibular fascia was appreciated inferiorly along the submandibular gland, this was incised allowing for identification of the digastric muscle.  Digastric tunnel was performed posteriorly to the level of the sternocleidomastoid muscle.  The fascia along the sternocleidomastoid muscle was then dissected along the anterior aspect until the cranial nerve XI was identified.  Level 2A contents were then dissected off the floor of the neck including levels 3 and 4.  Preservation of the phrenic nerve was obtained by identification, and subsequently cross-clamping fibrofatty tissue and lymph nodes just adjacent to the jugular vein inferiorly at level 4.  The specimen was then mobilized over the internal jugular vein with preservation of hypoglossal nerve.  Levels 2, 3, 4 neck dissection specimens were then labeled appropriately, attached with staples, and sent for histopathological evaluation.,Attention was then turned to attempting to perform a partial laryngectomy up front with a possibility of total laryngectomy as discussed.  Subsequently, the strap muscles were separated in the midline.  The trachea was identified in the midline.  The thyroid isthmus was plicated using the Harmonic scalpel, and attention was then turned to transecting the strap muscles at the superior aspect of the thyroid cartilage.  Once this was performed, sinuses were mobilized from the thyroid cartilage both on the right and left side respectively.  The cricothyroid joint was then freed on the left side and then on the right side with noting on the right side that this cartilage was a bit more irregular.  Attention was then turned to performing a cricothyrotomy.  Upon performing this, it was obvious that there was tumor just above the level of the cricothyrotomy incision.  A #7 anode tube was then placed in this area and secured.  Attention was then turned to performing the laryngotomy at the level of the petiole of epiglottis.  Subsequently, the cuts were made on the left side with visualization of the vocalis process and coming down to the level of the cricoid cartilage, and the thyroid cartilage was then intentionally fractured along the anterior spine.  It was evident that this tumor had extended more than 1 cm into the subglottic region.  Careful dissection of larynx from an inferior margin and portion of cricoid cartilage resection then was performed posteriorly, though it was evident that the cricoid cartilage was invaded.  Frozen section biopsy then confirmed this finding as read by Dr. X of Surgical Pathology.,In light of this finding with cartilaginous invasion and inability to preserve the cricoid cartilage, the patient's case was then converted into a total laryngectomy.  Subsequently, the trachea was transected at the level 3, 4 tracheal ring into cartilaginous space and anterior tracheal stoma was fashioned using 3-0 vertical mattress sutures for the skin.  A W-plasty was also performed to allow for enlargement of the stoma.  Attention was then turned to identifying the common parting wall of the trachea and the esophagus.  Attention was then turned to resecting the hyoid bone.  The remainder of the specimen cuts were made superior from sinus preserving a modest amount of pharyngeal mechanism.  The wound was copiously irrigated.  Subsequently, a tracheoesophageal puncture site was performed using a right-angled hemostat at about approximately 1 cm from the posterior tracheal wall superior aspect.  Once this was performed, a running 3-0 canal stitch was used to close the pharynx.  Subsequently, interrupted 4-0 chromic stitches were then used as reinforcement line from superior to inferior, and fibrin glue was applied.  Two #10 JP drains were placed on the right side and one on the left side and secured appropriately with 3-0 nylon.  The wound was then closed using interrupted 3-0 Vicryl for the platysma and staples for the skin.  The patient tolerated the procedure well and was brought to the Weinberg Intensive Care Unit with the endotracheal tube still in place to be decannulated later.
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DESCRIPTION: Squamous cell carcinoma of the larynx.  Total laryngectomy, right level 2, 3, 4 neck dissection, tracheoesophageal puncture, cricopharyngeal myotomy, right thyroid lobectomy.

ent - otolaryngology, laryngectomy, neck dissection, tracheoesophageal, cricopharyngeal myotomy, thyroid lobectomy, squamous cell carcinoma, larynx, thyroid cartilage, cricoid cartilage, total laryngectomy, thyroid, cartilage

The situation involves a complex and major surgical procedure for a patient with squamous cell carcinoma of the larynx. This type of surgery, which includes a total laryngectomy and neck dissection, is typically high-stakes due to the potential risks and significant implications for the patient's quality of life, including the possible loss of the ability to speak and swallow. The patient was informed of substantial risks, such as nerve injuries and the need for ongoing medical care. The decision to opt for surgery over chemoradiation further highlights the severity and complexity of the case. Given the nature of the surgery and the life-altering consequences, this situation is high-stakes.