Medical Specialty: Office Notes
Sample Name: Normal Male Exam Template - 2

MALE PHYSICAL EXAMINATION,Eye:  Eyelids normal color, no edema.  Conjunctivae with no erythema, foreign body, or lacerations.  Sclerae normal white color, no jaundice.  Cornea clear without lesions.  Pupils equally responsive to light.  Iris normal color, no lesions.  Anterior chamber clear.  Lacrimal ducts normal.  Fundi clear.,Ear:  External ear has no erythema, edema, or lesions.  Ear canal unobstructed without edema, discharge, or lesions.  Tympanic membranes clear with normal light reflex.  No middle ear effusions.,Nose:  External nose symmetrical.  No skin lesions.  Nares open and free of lesions.  Turbinates normal color, size and shape.  Mucus clear.  No internal lesions.,Throat:  No erythema or exudates.  Buccal mucosa clear.  Lips normal color without lesions.  Tongue normal shape and color without lesion.  Hard and soft palate normal color without lesions.  Teeth show no remarkable features.  No adenopathy.  Tonsils normal shape and size.  Uvula normal shape and color.,Neck:  Skin has no lesions.  Neck symmetrical.  No adenopathy, thyromegaly, or masses.  Normal range of motion, nontender.  Trachea midline.,Chest:  Symmetrical.  Clear to auscultation bilaterally.  No wheezing, rales or rhonchi.  Chest nontender.  Normal lung excursion.  No accessory muscle use.,Cardiovascular:  Heart has regular rate and rhythm with no S3 or S4.  Heart rate is normal.,Abdominal:  Soft, nontender, nondistended, bowel sounds present.  No hepatomegaly, splenomegaly, masses, or bruits.,Genital:  Penis normal shape without lesions.  Testicles normal shape and contour without tenderness.  Epididymides normal shape and contour without tenderness.  Rectum normal tone to sphincter.  Prostate normal shape and contour without nodules.  Stool hemoccult negative.  No external hemorrhoids.  No skin lesions.,Musculoskeletal:  Normal strength all muscle groups.  Normal range of motion all joints.  No joint effusions.  Joints normal shape and contour.  No muscle masses.,Foot:  No erythema.  No edema.  Normal range of motion all joints in the foot.  Nontender.  No pain with inversion, eversion, plantar or dorsiflexion.,Ankle:  Anterior and posterior drawer test negative.  No pain with inversion, eversion, dorsiflexion, or plantar flexion.  Collateral ligaments intact.  No joint effusion, erythema, edema, crepitus, ecchymosis, or tenderness.,Knee:  Normal range of motion.  No joint effusion, erythema, nontender.  Anterior and posterior drawer tests negative.  Lachman's test negative.  Collateral ligaments intact.  Bursas nontender without edema.,Wrist:  Normal range of motion.  No edema or effusion, nontender.  Negative Tinel and Phalen tests.  Normal strength all muscle groups.,Elbow:  Normal range of motion.  No joint effusion or erythema.  Normal strength all muscle groups.  Nontender.  Olecranon bursa flat and nontender, no edema.  Normal supination and pronation of forearm.  No crepitus.,Hip:  Negative swinging test.  Trochanteric bursa nontender.  Normal range of motion.  Normal strength all muscle groups.  No pain with eversion and inversion.  No crepitus.  Normal gait.,Psychiatric:  Alert and oriented times four.  No delusions or hallucinations, no loose associations, no flight of ideas, no tangentiality.  Affect is appropriate.  No psychomotor slowing or agitation.  Eye contact is appropriate.
---
DESCRIPTION: An example/template for a routine normal male physical exam.

office notes, male exam, normal, physical exam, normal range of motion, male physical, nontender, lesions, dorsiflexion, sclerae, contour, muscle, erythema, joints, edema, shape,

The provided text is a comprehensive template for documenting a routine normal male physical exam. It outlines observations that typically indicate no immediate health concerns or abnormalities. This is a standardized procedure used by healthcare professionals to record findings during a standard check-up. As such, it involves no immediate decision-making or diagnoses that could have high-stakes implications unless abnormalities or acute conditions were documented, which is not the case in this scenario. Thus, it constitutes a low-stakes situation, typical of routine healthcare documentation.


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

Medical Specialty: Surgery
Sample Name: Adenotonsillectomy - 2

POSTOPERATIVE DIAGNOSIS:  Adenotonsillitis with hypertrophy.,OPERATION PERFORMED:  Adenotonsillectomy.,ANESTHESIA:  General endotracheal.,INDICATIONS:  The patient is a very nice patient with adenotonsillitis with hypertrophy and obstructive symptoms.  Adenotonsillectomy is indicated.,DESCRIPTION OF PROCEDURE:  The patient was placed on the operating room table in the supine position.  After adequate general endotracheal anesthesia was administered, table was turned and shoulder roll was placed on the shoulders and face was draped in clean fashion.  A McIvor mouth gag was applied.  The tongue was retracted anteriorly and the McIvor was gently suspended from a Mayo stand.  A red rubber Robinson catheter was inserted through the left naris and the soft palate was retracted superiorly.  The adenoids were removed with suction electrocautery under mere visualization.  The left tonsil was grasped with a curved Allis forceps, retracted medially and the anterior tonsillar pillar was incised with Bovie electrocautery.  The tonsil was removed from the superior and inferior pole using Bovie electrocautery in its entirety in the subcapsular fashion.  The right tonsil was grasped in the similar fashion and retracted medially and the anterior tonsillar pillar was incised with Bovie electrocautery.  The tonsil was removed from the superior pole and inferior pole using Bovie electrocautery in its entirety in the subcapsular fashion.  The inferior, middle and superior pole vessels were further cauterized with suction electrocautery.  Copious saline irrigation of the oral cavity was then performed.  There was no further identifiable bleeding at the termination of the procedure.  The estimated blood loss was less than 10 mL.  The patient was extubated in the operating room, brought to the recovery room in satisfactory condition.  There were no intraoperative complications.
---
DESCRIPTION: Adenotonsillectomy.  Adenotonsillitis with hypertrophy.  The patient is a very nice patient with adenotonsillitis with hypertrophy and obstructive symptoms.  Adenotonsillectomy is indicated.

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

The described procedure is a routine adenotonsillectomy, which is a common surgery usually performed on children for conditions like adenotonsillitis with hypertrophy. The operation appears to have gone smoothly with no complications and minimal blood loss. While surgery always carries some inherent risk, this particular procedure is not generally considered high-stakes compared to more complex surgeries. The patient's condition was satisfactory post-operation, further indicating a successful and standard surgery.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: General Medicine
Sample Name: Gen Med Consult - 20

SUBJECTIVE:,  This is an 11-year-old female who comes in for two different things.  1.  She was seen by the allergist.  No allergies present, so she stopped her Allegra, but she is still real congested and does a lot of snorting.  They do not notice a lot of snoring at night though, but she seems to be always like that.  2.  On her right great toe, she has got some redness and erythema.  Her skin is kind of peeling a little bit, but it has been like that for about a week and a half now.,PAST MEDICAL HISTORY:,  Otherwise reviewed and noted.,CURRENT MEDICATIONS:,  None.,ALLERGIES TO MEDICINES:,  None.,FAMILY SOCIAL HISTORY:,  Everyone else is healthy at home.,REVIEW OF SYSTEMS:,  She has been having the redness of her right great toe, but also just a chronic nasal congestion and fullness.  Review of systems is otherwise negative.,PHYSICAL EXAMINATION:,General:  Well-developed female, in no acute distress, afebrile.,HEENT:  Sclerae and conjunctivae clear.  Extraocular muscles intact.  TMs clear.  Nares patent.  A little bit of swelling of the turbinates on the left.  Oropharynx is essentially clear.  Mucous membranes are moist.,Neck:  No lymphadenopathy.,Chest:  Clear.,Abdomen:  Positive bowel sounds and soft.,Dermatologic:  She has got redness along the lateral portion of her right great toe, but no bleeding or oozing.  Some dryness of her skin.  Her toenails themselves are very short and even on her left foot and her left great toe the toenails are very short.,ASSESSMENT:,1.  History of congestion, possibly enlarged adenoids, or just her anatomy.,2.  Ingrown toenail, but slowly resolving on its own.,PLAN:,1.  For the congestion, we will have ENT evaluate.  Appointment has been made with Dr. XYZ for in a couple of days.,2.  I told her just Neosporin for her toe, letting the toenail grow out longer.  Call if there are problems.
---
DESCRIPTION: 11-year-old female.  History of congestion, possibly enlarged adenoids.

general medicine, enlarged adenoids, adenoids, oropharynx, congestion, toenails, toe,

The medical case involves an 11-year-old female with minor, non-life-threatening issues: chronic nasal congestion and a resolving ingrown toenail. These conditions, while potentially uncomfortable, are not urgent or critical. There is a plan in place, including an ENT evaluation and basic treatment for the toe, reflecting that medical action can proceed without immediate high risks or severe outcomes. The patient's general well-being is normal, with no acute distress noted.


Medical Specialty: Consult - History and Phy.
Sample Name: Huntington's Disease

CC:, Slowing of motor skills and cognitive function.,HX: ,This 42 y/o LHM presented on 3/16/93 with gradually progressive deterioration of motor and cognitive skills over 3 years. He had difficulty holding a job. His most recent employment ended 3 years ago as he was unable to learn the correct protocols for the maintenance of a large conveyer belt. Prior to that, he was unable to hold a job in the mortgage department of a bank as could not draw and figure property assessments. For 6 months prior to presentation, he and his wife noted (his) increasingly slurred speech and slowed motor skills (i.e. dressing himself and house chores). His walk became slower and he had difficulty with balance. He became anhedonic and disinterested in social activities, and had difficulty sleeping for frequent waking and restlessness. His wife noticed "fidgety movements" of his hand and feet.,He was placed on trials of Sertraline and Fluoxetine for depression 6 months prior to presentation by his local physician. These interventions did not appear to improve his mood and affect.,MEDS:, Fluoxetine.,PMH: ,1)Right knee arthroscopic surgery 3 yrs ago. 2)Vasectomy.,FHX:, Mother died age 60 of complications of Huntington Disease (dx at UIHC). MGM and two MA's also died of Huntington Disease. His 38 y/o sister has attempted suicide twice.,He and his wife have 2 adopted children.,SHX: ,unemployed. 2 years of college education. Married 22 years.,ROS: ,No history of Dopaminergic or Antipsychotic medication use.,EXAM:, Vital signs normal.,MS: A&O to person, place, and time. Dysarthric speech with poor respiratory control.,CN: Occasional hypometric saccades in both horizontal directions. No vertical gaze abnormalities noted. Infrequent spontaneous forehead wrinkling and mouth movements. The rest of the CN exam was unremarkable.,Motor: Full strength throughout and normal muscle tone and bulk. Mild choreiform movements were noted in the hands and feet.,Sensory: unremarkable.,Coord: unremarkable.,Station/Gait: unremarkable, except that during tandem walking mild dystonic and choreiform movements of BUE became more apparent.,Reflexes: 2/2 throughout. Plantar responses were flexor, bilaterally.,There was no motor impersistence on tongue protrusion or hand grip.,COURSE:, He was thought to have early manifestations of Huntington Disease. A HCT was unremarkable. Elavil 25mg qhs was prescribed. Neuropsychologic assessment revealed mild anterograde memory loss only.,His chorea gradually worsened during the following 4 years. He developed motor impersistence and more prominent slowed saccadic eye movements. His mood/affect became more labile.,6/5/96 genetic testing revealed a 45 CAg trinucleotide repeat band consistent with Huntington Disease. MRI brain, 8/23/96, showed caudate nuclei atrophy, bilaterally.
---
DESCRIPTION: Caudate Nuclei atrophy, bilaterally, in patient with Huntington Disease.

This case involves the diagnosis and management of Huntington's Disease, a progressive and fatal genetic disorder that severely impacts the patient's quality of life. Given the hereditary nature and potential for serious psychological and physical symptoms, this is a high-stakes medical situation. The condition also carries significant emotional implications for the patient and their family, including potential genetic transmission to offspring. Therefore, the stakes are high due to both immediate healthcare needs and long-term family planning and psychological considerations.


Medical Specialty: General Medicine
Sample Name: Normal ENT Exam - 1

EARS, NOSE, MOUTH AND THROAT,EARS/NOSE: , The auricles are normal to palpation and inspection without any surrounding lymphadenitis.  There are no signs of acute trauma.  The nose is normal to palpation and inspection externally without evidence of acute trauma.  Otoscopic examination of the auditory canals and tympanic membranes reveals the auditory canals without signs of mass lesion, inflammation or swelling.  The tympanic membranes are without disruption or infection.  Hearing intact bilaterally to normal level speech.  Nasal mucosa, septum and turbinate examination reveals normal mucous membranes without disruption or inflammation.  The septum is without acute traumatic lesions or disruption.  The turbinates are without abnormal swelling.  There is no unusual rhinorrhea or bleeding.  ,LIPS/TEETH/GUMS:  ,The lips are without infection, mass lesion or traumatic lesions.  The teeth are intact without obvious signs of infection.  The gingivae are normal to palpation and inspection.  ,OROPHARYNX:  ,The oral mucosa is normal.  The salivary glands are without swelling.  The hard and soft palates are intact.  The tongue is without masses or swelling with normal movement.  The tonsils are without inflammation.  The posterior pharynx is without mass lesion with good patent oropharyngeal airway.
---
DESCRIPTION: Sample normal ear, nose, mouth, and throat exam.

general medicine, oral mucosa, lips, hearing, auditory canals, tympanic membranes, traumatic lesions, mouth, throat, trauma, nose, membranes, inflammation, infection, swelling,

The situation involves a standard ENT exam with normal findings. There are no abnormalities or urgent issues reported, meaning the stakes related to this situation are low. It is a routine examination rather than an acute or complex medical problem, thus not involving high-stakes decision making.


Medical Specialty: ENT - Otolaryngology
Sample Name: ENT Consult

HISTORY:,  The patient is a 51-year-old female that was seen in consultation at the request of Dr. X on 06/04/2008 regarding chronic nasal congestion, difficulty with swallowing, and hearing loss.  The patient reports that she has been having history of recurrent sinus infection, averages about three times per year.  During the time that she gets the sinus infections, she has nasal congestion, nasal drainage, and also generally develops an ear infection as well.  The patient does note that she has been having hearing loss.  This is particular prominent in the right ear now for the past three to four years.  She does note popping after blowing the nose.  Occasionally, the hearing will improve and then it plugs back up again.  She seems to be plugged within the nasal passage, more on the right side than the left and this seems to be year round issue with her.  She tried Flonase nasal spray to see if this help with this and has been taking it, but has not seen a dramatic improvement.  She has had a history of swallowing issues and that again secondary to the persistent postnasal drainage.  She feels that she is having a hard time swallowing at times as well.  She has complained of a lump sensation in the throat that tends to come and go.  She denies any cough, no hemoptysis, no weight change.  No night sweats, fever or chills has been noted.  She is having at this time no complaints of tinnitus or vertigo.  The patient presents today for further workup, evaluation, and treatment of the above-listed symptoms.,REVIEW OF SYSTEMS:  ,ALLERGY/IMMUNOLOGIC:  History of seasonal allergies.  She also has severe allergy to penicillin and bee stings.,CARDIOVASCULAR:  Pertinent for hypercholesterolemia.,PULMONARY:  She has a history of cough, wheezing.,GASTROINTESTINAL:  Negative.,GENITOURINARY:  Negative.,NEUROLOGIC:  She has had a history of TIAs in the past.,VISUAL:  She does have history of vision change, wears glasses.,DERMATOLOGIC:  Negative.,ENDOCRINE:  Negative.,MUSCULOSKELETAL:  History of joint pain and bursitis.,CONSTITUTIONAL:  She has a history of chronic fatigue.,ENT:  She has had a history of cholesteatoma removal from the right middle ear and previous tympanoplasty with a progressive hearing loss in the right ear over the past few years according to the patient.,PSYCHOLOGIC:  History of anxiety, depression.,HEMATOLOGIC:  Easy bruising.,PAST SURGICAL HISTORY: , She has had right tympanoplasty in 1984.  She has had a left carotid endarterectomy, cholecystectomy, two C sections, hysterectomy, and appendectomy.,FAMILY HISTORY: , Mother, history of vaginal cancer and hypertension.  Brother, colon CA.  Father, hypertension.,CURRENT MEDICATIONS: , Aspirin 81 mg daily.  She takes vitamins one a day.  She is on Zocor, Desyrel, Flonase, and Xanax.  She also has been taking Chantix for smoking cessation.,ALLERGIES: , Penicillin causes throat swelling.  She also notes the bee sting allergy causes throat and tongue swelling.,SOCIAL HISTORY: , The patient is single.  She is unemployed at this time.  She is a smoker about a pack and a half for 38 years and notes rare alcohol use.,PHYSICAL EXAMINATION:  ,VITAL SIGNS:  Her blood pressure 128/78, temperature is 98.6, pulse 80 and regular.,GENERAL:  The patient is an alert, cooperative, well-developed 51-year-old female.  She has a normal-sounding voice and good memory.,HEAD & FACE:  Inspected with no scars, lesions or masses noted.  Sinuses palpated and are normal.  Salivary glands also palpated and are normal with no masses noted.  The patient also has full facial function.,CARDIOVASCULAR:  Heart regular rate and rhythm without murmur.,RESPIRATORY:  Lungs auscultated and noted to be clear to auscultation bilaterally with no wheezing or rubs and normal respiratory effort.,EYES:  Extraocular muscles were tested and within normal limits.,EARS:  Right ear, the external ear is normal.  The ear canal is clean and dry.  The drum is intact.  She has got severe tympanosclerosis of the right tympanic membrane and Weber exam does lateralize to the right ear indicative of a conductive loss.  Left ear, the external ear is normal.  The ear canal is clean and dry.  The drum is intact and mobile with grossly normal hearing.  The audiogram does reveal normal hearing in the left ear.  She has got a mild conductive loss throughout all frequency ranges in the right ear with excellent discrimination scores noted bilaterally.  Tympanograms, there was no adequate seal obtained on the right side.  She has a normal type A tympanogram, left side.,NASAL:  Reveals a deviated nasal septum to the left, clear drainage, large inferior turbinates, no erythema.,ORAL:  Oral cavity is normal with good moisture.  Lips, teeth and gums are normal.  Evaluation of the oropharynx reveals normal mucosa, normal palates, and posterior oropharynx.  Examination of the larynx with a mirror reveals normal epiglottis, false and true vocal cords with good mobility of the cords.  The nasopharynx was briefly examined by mirror with normal appearing mucosa, posterior choanae and eustachian tubes.,NECK:  The neck was examined with normal appearance.  Trachea in the midline.  The thyroid was normal, nontender, with no palpable masses or adenopathy noted.,NEUROLOGIC:  Cranial nerves II through XII evaluated and noted to be normal.  Patient oriented times 3.,DERMATOLOGIC:  Evaluation reveals no masses or lesions.  Skin turgor is normal.,PROCEDURE: , Please note a fiberoptic laryngoscopy was also done at today's visit for further evaluation because of the patient's dysphagia and throat symptoms.  Findings do reveal moderately deviated nasal septum to the left, large inferior turbinates noted.  The nasopharynx does reveal moderate adenoid pad within this midline.  It is nonulcerated.  The larynx revealed both cords to be normal.  She does have mild lingual tonsillar hypertrophy as well.,IMPRESSION:  ,1.  Persistent dysphagia.  I think secondary most likely to the persistent postnasal drainage.,2.  Deviated nasal septum.,3.  Inferior turbinate hypertrophy.,4.  Chronic rhinitis.,5.  Conductive hearing loss, right ear with a history of cholesteatoma of the right ear.
---
DESCRIPTION: Persistent dysphagia.  Deviated nasal septum.  Inferior turbinate hypertrophy.  Chronic rhinitis. Conductive hearing loss.  Tympanosclerosis.

The situation described involves a comprehensive ENT consultation for a patient with chronic conditions such as dysphagia, deviated nasal septum, and conductive hearing loss. While these symptoms can significantly affect the patient's quality of life, they do not immediately threaten the patient's survival or require urgent medical intervention. The assessment does not indicate acute or life-threatening conditions; hence it's more about managing chronic issues rather than immediate life or limb-saving actions. Thus, this situation is not extremely high-stakes medically, as it doesn't involve an emergency but rather ongoing management and evaluation.


Medical Specialty: Surgery
Sample Name: Heart Catheterization, Ventriculography, & Angiography - 6

PREOPERATIVE DIAGNOSES,1.  Dyspnea on exertion with abnormal stress echocardiography.,2.  Frequent PVCs.,3.  Metabolic syndrome.,POSTOPERATIVE DIAGNOSES,1.  A 50% distal left main and two-vessel coronary artery disease with normal left ventricular systolic function.,2.  Frequent PVCs.,3.  Metabolic syndrome.,PROCEDURES,1.  Left heart catheterization with left ventriculography.,2.  Selective coronary angiography.,COMPLICATIONS: , None.,DESCRIPTION OF PROCEDURE: , After informed consent was obtained, the patient was brought to the Cardiac Catheterization Laboratory in fasting state.  Both groins were prepped and draped in the usual sterile fashion.  Xylocaine 1% was used as local anesthetic.  Versed and fentanyl were used for conscious sedation.  Next, a #6-French sheath was placed in the right femoral artery using modified Seldinger technique.  Next, selective angiography of the left coronary artery was performed in multiple views using #6-French JL4 catheter.  Next, selective angiography of the right coronary artery was performed in multiple views using #6-French 3DRC catheter.  Next, a #6-French angle pigtail catheter was advanced into the left ventricle.  The left ventricular pressure was then recorded.  Left ventriculography was the performed using 36 mL of contrast injected over 3 seconds.  The left heart pull back was then performed.  The catheter was then removed.,Angiography of the right femoral artery was performed.  Hemostasis was obtained by Angio-Seal closure device.  The patient left the Cardiac Catheterization Laboratory in stable condition.,HEMODYNAMICS,1.  LV pressure was 163/0 with end-diastolic pressure of 17.  There was no significant gradient across the aortic valve.,2.  Left ventriculography showed old inferior wall hypokinesis.  Global left ventricular systolic function is normal.  Estimated ejection fraction was 58%.  There is no significant mitral regurgitation.,3.  Significant coronary artery disease.,4.  The left main is approximately 7 or 8 mm proximally.  It trifurcates into left anterior descending artery, ramus intermedius artery, and left circumflex artery.  The distal portion of the left main has an ulcerated excentric plaque, up to about 50% in severity.,5.  The left anterior descending artery is around 4 mm proximally.  It extends slightly beyond the apex into the inferior wall.  It gives rises to several medium size diagonal branches as well as small to medium size multiple septal perforators.  At the ostium of the left anterior descending artery, there was an eccentric plaque up to 70% to 80%, best seen in the shallow LAO with caudal angulation.,There was no other flow-limiting disease noted in the rest of the left anterior descending artery or its major branches.,The ramus intermedius artery is around 3 mm proximally, but shortly after its origin, it bifurcates into two medium size branches.  There was no significant disease noted in the ramus intermedius artery however.,The left circumflex artery is around 2.5 mm proximally.  It gave off a recurrent atrial branch and a small AV groove branch prior to terminating into a bifurcating medium size obtuse marginal branch.  The mid to distal circumflex has a moderate disease, which is relatively diffuse up to about 40% to 50%.,The right coronary artery is around 4 mm in diameter.  It gives off conus branch, two medium size acute marginal branches, relatively large posterior descending artery and a posterior lateral branch.  In the mid portion of the right coronary artery at the origin of the first acute marginal branch, there is a relatively discrete stenosis of about 80% to 90%.  Proximally, there is an area of eccentric plaque, but seem to be non-flow limiting, at best around 20% to 30%.  Additionally, there is what appears to be like a shell-like lesion in the proximal segment of the right coronary artery as well.  The posterior descending artery has an eccentric plaque of about 40% to 50% in its mid segment.,PLAN:  ,Plan to consult cardiovascular surgery for consideration of coronary artery bypass surgery.  Continue risk factor modification, aspirin, and beta blocker.
---
DESCRIPTION: Left heart catheterization with left ventriculography and selective coronary angiography.  A 50% distal left main and two-vessel coronary artery disease with normal left ventricular systolic function.  Frequent PVCs.  Metabolic syndrome.

surgery, heart catheterization, ventriculography, coronary angiography, dyspnea, metabolic syndrome, two-vessel coronary artery disease, echocardiography, selective coronary angiography, anterior descending artery, branches, coronary, angiography, artery, catheterization,

The described medical procedure and findings involve heart catheterization along with angiography. This is typically conducted to assess coronary artery disease, which is a serious condition that can lead to heart attacks and other severe cardiovascular events. The procedure itself is invasive and carries risks, although no complications were noted in this instance. Given the identification of significant coronary artery disease (with up to 80-90% stenosis in some arteries) and the potential need for coronary artery bypass surgery, the stakes are high. The plan involves consulting cardiovascular surgery, which is a major decision impacting the patient's health significantly. Therefore, this scenario involves a critical evaluation of a patient's cardiovascular condition, guiding potential surgical intervention.


Medical Specialty: Surgery
Sample Name: Heart Catheterization, Ventriculography, & Angiography - 10

PROCEDURE: , Left heart catheterization, left and right coronary angiography, left ventricular angiography, and intercoronary stenting of the right coronary artery.,PROCEDURE IN DETAIL:  ,The patient was brought to the Catheterization Laboratory.  After informed consent, he was medicated with Versed and fentanyl.  The right groin was prepped and draped, and infiltrated with 2% Xylocaine.  Percutaneously, #6-French arterial sheath was placed.  Selective native left and right coronary angiography was performed followed by left ventricular angiography.  The patient had a totally occluded right coronary.  We initially started with a JR4 guide.  We were able to a sport wire through the total occlusion and saw a very tight stenosis.  We were able to get a 30 x 13 mm power saver balloon into the stenosis and dilated.  We then attempted to put a 30 x 12 mm stent across the stenosis, but we had very little guide support, the guide kept coming out.  We then switched to an AL1 guide and that too did not enable us to get anything to cross this lesion.  We finally had to go an AL2 guide, we were concerned that this could cause some proximal dissection.  That guided seated, we did have initial difficulty getting the wire back across the stenosis, and we did see a little staining suggesting we did have some tearing from the guide tip.  The surgeons were put on notice in case we could not get this vessel open, but we were able to re-cross with a sport wire.  We then re-dilated the area of stenosis and with good guide support, we were able to get a 30 x 23 mm Vision stent, where the lesion was and post-dilated it to 18 atmospheres.  Routine angiography did show that the distal posterolateral branch seems to be occluded, whether this was from distal wire dissection or distal thrombosis was unclear, but we were able to re-wire that area and get a 25 x12 Vision balloon and dilate the area and re-establish flow to the small segment.  We then came back because of the residual dissection proximal to the first stent and put a 30 x15 mm Vision stent at 18 atmospheres.  Final angiography showed resolution of the dissection.  We could see a little staining extrinsic to the stent.  No perforation and excellent flow.  During the intervention, we did give a bolus and drip of Angiomax.  At the end of the procedure, we stopped the Angiomax and gave 600 mg of Plavix.  We did a right femoral angiogram; however, the Angio-Seal plug could not take, so we used manual pressure and a Femostop.  We transported the patient to his room in stable condition.,ANGIOGRAPHIC DATA:,  Left main coronary is normal.  Left anterior descending artery has a fair amount of wall disease proximally about 50 to 60% stenosis of the LAD before it bifurcates into diagonal.  The diagonal does appear to have about 50% osteal stenosis.  There is a lot of plaquing further down the diagonal, but good flow.  The rest of the LAD looked good pass the proximal 60% stenosis and after the diagonal branch.  Circumflex artery was nondominant vessel, consisting of an obtuse marginal vessel.  The first obtuse marginal had a long 50% narrowing and then the AV groove branch was free of any disease.  Some mild collaterals to the right were seen.  Right coronary angiography revealed a total occlusion of the right coronary, just about 0.5 cm after its origin.  After we got a wire across the area of occlusion, we could see some thrombosis and a 99% stenosis just at the curve.  Following the balloon angioplasty, we established good flow down the distal vessel.  We still had about residual 70% stenosis.  When we had to go back with the AL2 guide, we could see a little bit of staining in the proximal portion of the vessel that we did not notice previously and we felt that the tip of the guide caused a little bit of intimal dissection.  We re-dilated and then deployed.  Repeat angiography now did show some hang up off dye distally.  We never did have the wire that far down, so this was probably felt to be due to distal embolization of some thrombus.  After deploying the stent, we had total resolution of the original lesion.  We then directed our attention to the posterolateral branch, which the remainder of the vessel was patent giving off a large PDA.  The posterolateral branch appeared to be occluded in its mid portion.  We got a wire through and dilated this.  We then came back and put a second stent in the proximal area of the right coronary proximal and abutting to the previous stent.  Repeat angiography now showed no significant dissection, a little bit of contrast getting extrinsic to the stent probably in a little subintimal pouch, but this was excluded by the stent.  There were no filling defects in the stent and excellent flow.  The distal posterolateral branch did open up, although it was little under-filled and there may have been some mild residual disease there.,IMPRESSION: , Atherosclerotic heart disease with total occlusion of right coronary, successfully stented to zero residual with repair of a small proximal dissection.  Minor distal disease of the posterolateral branch and 60% proximal left anterior descending coronary artery stenosis and 50% diagonal stenosis along with 50% stenosis of the first obtuse marginal branch.
---
DESCRIPTION: Left heart catheterization, left and right coronary angiography, left ventricular angiography, and intercoronary stenting of the right coronary artery.

surgery, heart catheterization, coronary angiography, ventricular angiography, intercoronary stenting, intercoronary, coronary, stenting, stenosis, angiography

This procedure description involves a complex and delicate series of interventions on the heart’s vasculature, including dealing with total occlusion of the right coronary artery and potential complications like dissection or perforation. The successful outcome and stable condition of the patient indicate careful management of high-stakes variables. Such cardiac procedures, given the critical nature of the cardiac system and the potential for catastrophic outcomes if complications aren’t managed, are inherently high-stakes.


Medical Specialty: ENT - Otolaryngology
Sample Name: CT Neck

TECHNIQUE: , Sequential axial CT images were obtained from the base of the brain to the thoracic inlet following the uneventful administration of 100 CC Optiray 320 intravenous contrast.,FINDINGS:,  Scans through the base of the brain are unremarkable.  The oropharynx and nasopharynx are within normal limits.  The airway is patent.  The epiglottis and epiglottic folds are normal.  The thyroid, submandibular, and parotid glands enhance homogenously.  The vascular and osseous structures in the neck are intact.  There is no lymphadenopathy.  The visualized lung apices are clear.,IMPRESSION:  ,No acute abnormalities.
---
DESCRIPTION: Common CT Neck template.

Common CT Neck template.

ent - otolaryngology, sequential axial ct images, optiray, parotid glands, epiglottic folds, epiglottis, base of the brain, ct neckNOTE

The CT Neck scan results indicate that everything is within normal limits and there are no acute abnormalities identified. Therefore, this represents a routine and normal finding in the medical field of otolaryngology. The situation does not indicate any immediate danger or high-stakes scenarios because there are no urgent or severe findings that require immediate intervention.


Medical Specialty: Urology
Sample Name: Circumcision Followup

REASON FOR VISIT: , Followup circumcision.,HISTORY OF PRESENT ILLNESS: , The patient had his circumcision performed on 09/16/2007 here at Children's Hospital.  The patient had a pretty significant phimosis and his operative course was smooth.  He did have a little bit of bleeding when he woke in recovery room, which required placement of some additional sutures, but after that, his recovery has been complete.  His mom did note that she had to him a couple of days of oral analgesics, but he seems to be back to normal and pain free now.  He is having no difficulty urinating, and his bowel function remains normal.,PHYSICAL EXAMINATION:  ,Today, The patient looks healthy and happy.  We examined his circumcision site.  His Monocryl sutures are still in place.  The healing is excellent, and there is only a mild amount of residual postoperative swelling.  There was one area where he had some recurrent adhesions at the coronal sulcus, and I gently lysed this today and applied antibiotic ointment showing this to mom had to especially lubricate this area until the healing is completed.,IMPRESSION: , Satisfactory course after circumcision for severe phimosis with no perioperative complications.,PLAN:  ,The patient came in followup for his routine care with Dr. X, but should not need any further routine surgical followup unless he develops any type of difficulty with this surgical wound.  If that does occur, we will be happy to see him back at any time.,
---
DESCRIPTION: Followup circumcision.  The patient had a pretty significant phimosis and his operative course was smooth.  Satisfactory course after circumcision for severe phimosis with no perioperative complications.

urology, circumcision, adhesions, followup circumcision, sutures, phimosis,

The situation described involves a routine follow-up after a circumcision surgery. The procedure seems to have been straightforward, and the follow-up report indicates no major complications post-surgery. The patient's healing is described as excellent with only mild swelling and some minor issues with adhesions that were addressed. Since there are no current complications and the patient is recovering well, this is a low-stakes medical situation, particularly because it involves a pediatric routine surgical follow-up where expected outcomes were achieved.


Medical Specialty: Radiology
Sample Name: CT Neck

TECHNIQUE: , Sequential axial CT images were obtained from the base of the brain to the thoracic inlet following the uneventful administration of 100 CC Optiray 320 intravenous contrast.,FINDINGS:,  Scans through the base of the brain are unremarkable.  The oropharynx and nasopharynx are within normal limits.  The airway is patent.  The epiglottis and epiglottic folds are normal.  The thyroid, submandibular, and parotid glands enhance homogenously.  The vascular and osseous structures in the neck are intact.  There is no lymphadenopathy.  The visualized lung apices are clear.,IMPRESSION:  ,No acute abnormalities.
---
DESCRIPTION: Common CT Neck template.

Common CT Neck template.

radiology, sequential axial ct images, optiray, parotid glands, epiglottic folds, epiglottis, base of the brain, ct neckNOTE

The situation presented is a routine radiology report from a CT neck scan that shows no acute abnormalities or concerning findings. This is a common scenario in radiology practices where a CT scan results come back normal. There is no immediate threat to patient health or significant clinical decision-making involved based on this report alone.


Medical Specialty: Radiology
Sample Name: Laparoscopy - Drainage of Cyst

PREOPERATIVE DIAGNOSIS:,  Ovarian cyst, persistent.,POSTOPERATIVE DIAGNOSIS: , Ovarian cyst.,ANESTHESIA:,  General,NAME OF OPERATION:,  Diagnostic laparoscopy and drainage of cyst.,PROCEDURE:,  The patient was taken to the operating room, prepped and draped in the usual manner, and adequate anesthesia was induced.  An infraumbilical incision was made, and Veress needle placed without difficulty.  Gas was entered into the abdomen at two liters.  The laparoscope was entered, and the abdomen was visualized.  The second puncture site was made, and the second trocar placed without difficulty.  The cyst was noted on the left, a 3-cm, ovarian cyst.  This was needled, and a hole cut in it with the scissors.  Hemostasis was intact.  Instruments were removed.  The patient was awakened and taken to the recovery room in good condition.
---
DESCRIPTION: Diagnostic laparoscopy and drainage of cyst.

radiology, ovarian cyst, infraumbilical incision, drainage of cyst, diagnostic laparoscopy, laparoscopy, drainage, ovarian,

The procedure described is a routine medical intervention for an ovarian cyst, which is a common and generally low-risk surgical operation. Laparoscopy is a minimally invasive procedure often performed on an outpatient basis. The situation appears to be straightforward with no complications reported, and the patient was awakened and taken to recovery in good condition. Thus, this does not seem to involve high stakes compared to surgeries with higher risks of complications or where the patient's condition might be life-threatening.


Medical Specialty: Surgery
Sample Name: Ash Split Venous Port

ASH SPLIT VENOUS PORT,PROCEDURE DETAILS:  ,The patient was taken to the operating room and placed in supine position and monitored anesthesia care provided by the anesthetist.  The right anterior chest and supraclavicular fossa area, neck, and left side of chest were prepped with Betadine and draped in a sterile fashion.  Xylocaine 1% was infiltrated in the supraclavicular area and anterior chest along the planned course of the catheter.  The patient was placed into Trendelenburg position.,The right internal jugular vein was accessed by a supraclavicular 19-gauge, thin-walled needle as demonstrated by easy withdrawal of venous blood on the first pass of the needle.  Under fluoroscopic control, a J-wire was advanced into the right atrium.  The needle was removed and the skin puncture site enlarged to about 8 mm with the scalpel.  A second incision was made 5 cm inferior to the right midclavicular line, through which an Ash split catheter was advanced, using the tunneling rod, in a gently curving pass to exit the skin of the neck incision.  The tunneling needle was removed and the catheter split up to the marker as indicated in the recommended use of the catheter.,Sequential dilators were advanced over the J-wire under fluoroscopic control to dilate the subcutaneous tunnel followed by advancement of a dilator and sheath into the right superior vena cava under fluoroscopic control.  The dilator and wire were removed, leaving the sheath in position, through which a double-lumen catheter was advanced into the central venous system.  The sheath was peeled away, leaving the catheter into position.  Each port of the catheter was flushed with dilute heparinized saline.,The patient was returned to the flat position.  The catheter was secured to the skin of the anterior chest using 2-0 Ethilon suture placed through the suture "wings.",The neck incision was closed with 3-0 Vicryl subcuticular closure and pressure dressing applied.  Fluoroscopic examination of the chest revealed no evidence of pneumothorax upon completion of the procedure and the catheter was in excellent position.,The patient was returned to the recovery room for postoperative care.
---
DESCRIPTION: Ash split venous port insertion. The right anterior chest and supraclavicular fossa area, neck, and left side of chest were prepped with Betadine and draped in a sterile fashion.

surgery, ash split venous port, venous port, anterior chest, incision, dilators, sheath, port, supraclavicular, needle, fluoroscopic, venous, insertion, catheter

The procedure described is a surgical intervention involving the placement of a venous port, which is typically used for patients requiring long-term intravenous access, often for chemotherapy, dialysis, or other intensive treatments. The procedure involves accessing the internal jugular vein and using fluoroscopic guidance to ensure proper placement, alongside necessary measures to prevent complications such as infections or pneumothorax. These factors make it a high-stakes procedure due to the potential risks involved and the critical nature of its function for ongoing patient treatment.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Foreskin - Followup

REASON FOR VISIT: , Follow up consultation, second opinion, foreskin.,HISTORY OF PRESENT ILLNESS: , A 2-week-old who at this point has otherwise been doing well.  He has a relatively unremarkable foreskin.  At this point in time, he otherwise seems to be doing reasonably well.  The question is about the foreskin.  He otherwise has no other significant issues.  Severity low, ongoing since birth two weeks.  Thank you for allowing me to see this patient in consultation.,PHYSICAL EXAMINATION:,  Male exam.  Normal and under the penis, report normal uncircumcised 2-week-old.  He has a slightly insertion on the penile shaft from the median raphe of the scrotum.,IMPRESSION: , Slightly high insertion of the median raphe.  I see no reason he cannot be circumcised as long as they are careful and do a very complete Gomco circumcision.  This kid should otherwise do reasonably well.,PLAN:  ,Follow up as needed.  But my other recommendation is that this kid as I went over with the mother may actually do somewhat better if he simply has a formal circumcision at one year of age, but may do well with a person who is very accomplished doing a Gomco circumcision.
---
DESCRIPTION: Follow up consultation, second opinion, foreskin.

soap / chart / progress notes, formal circumcision, median raphe, penis, gomco circumcision, gomco, circumcision, foreskin,

The scenario involves a follow-up consultation for a 2-week-old child regarding their foreskin, seeking a second opinion. The situation is not critical as the foreskin condition is not severe and there is no immediate danger to the child’s health. The stakes involve deciding whether to perform a circumcision now or hold off until the child is older, which is more of a preference-oriented decision rather than an urgent medical need.


Medical Specialty: Pediatrics - Neonatal
Sample Name: Sports Physical - 3

SUBJECTIVE:,  This is a 12-year-old male who comes in for healthy checkups and sports physical.  No major concerns today.  He is little bit congested at times.  He has been told he is allergic to grasses.  They have done over-the-counter Claritin and that seems to help but he is always sniffling mother reports.  He has also got some dryness on his face as far as the skin and was wondering what cream he could put on.,PAST MEDICAL HISTORY:,  Otherwise, reviewed.  Very healthy.,CURRENT MEDICATIONS:,  Claritin p.r.n.,ALLERGIES TO MEDICINES:,  None.,FAMILY SOCIAL HISTORY:,  Everyone else is healthy at home currently.,DIETARY:,  He is on whole milk and does a variety of foods.  Growth chart is reviewed with mother.  Voids and stools well.,DEVELOPMENTAL:,  He is in seventh grade and going out for cross-country and track.  He is supposed to be wearing glasses, is not today.  We did not test his vision because he recently saw the eye doctor though we did discuss the need for him to wear glasses with mother.  His hearing was normal today and no concerns with speech.,PHYSICAL EXAMINATION:,General:  A well-developed, well-nourished male in no acute distress.,Dermatologic:  Without rash or lesion.,HEENT:  Head normocephalic and atraumatic.  Eyes:  Pupils equal, round and reactive to light.  Extraocular movements intact.  Red reflexes are present bilaterally.  Optic discs are sharp with normal vasculature.  Ears:  Tympanic membranes are gray, translucent with normal light reflex.  Nares are very congested.  Turbinates swollen and boggy.,Neck:  Supple without masses.,Chest:  Clear to auscultation and percussion, easy respirations.  No accessory muscle use.,Cardiovascular:  Regular rate and rhythm without murmurs, rubs, heaves or gallops.,Back:  Symmetric with no scoliosis or kyphosis noted.  Normal flexibility.  Femoral pulses 2+ and symmetric.,Abdomen:  Soft, nontender, nondistended without hepatosplenomegaly.,GU Exam:  Normal Tanner III male.  Testes descended bilaterally.  No abnormal rash, discharge, or scars.,Extremities:  Pink and warm.  Moves all extremities well with normal function and strength in the arms and legs.  Normal balance, station, and gait.  Normal speech.,Neurologic:  Nonfocal with normal speech, station, gait, and balance.,ASSESSMENT:,  Healthy Tanner III male, developing normally.,PLAN:,1.  Diet, growth, safety, drugs, violence, and social competence all discussed.,2.  Immunizations reviewed.,3.  We will place him on Clarinex 5 mg once daily, some Rhinocort-AQ nasal spray one spray each nostril once daily and otherwise discussed the importance of him wearing glasses.,4.  Return to clinic p.r.n. and at two to three years for a physical, otherwise return p.r.n.
---
DESCRIPTION: Healthy checkups and sports physical - 12 years old - Healthy Tanner III male, developing normally.

This medical case involves a routine checkup for a 12-year-old who exhibits general good health. The main concern is mild allergies managed with over-the-counter medications, and the importance of wearing glasses was discussed. There are no immediate health threats or severe medical conditions mentioned. This suggests a low-stakes situation as the primary objective is a normal evaluation with some follow-up recommendations.


Medical Specialty: Neurology
Sample Name: SOAP - Temporal Mass

SUBJECTIVE: , The patient is a 55-year-old African-American male that was last seen in clinic on 07/29/2008 with diagnosis of new onset seizures and an MRI scan, which demonstrated right contrast-enhancing temporal mass.  Given the characteristics of this mass and his new onset seizures, it is significantly concerning for a high-grade glioma.  ,OBJECTIVE: , The patient is alert and oriented times three, GCS of 15.  Cranial nerves II to XII are grossly intact.  Motor exam demonstrates 5/5 strength in all four extremities.  Sensation is intact to light touch, pain, temperature, and proprioception.  Cerebellar exam is intact.  Gait is normal and tandem on heels and toes.  Speech is appropriate.  Judgment is intact.  Pupils are equal and reactive to light.,ASSESSMENT AND PLAN: , The patient is a 55-year-old African-American male with a new diagnosis of rim-enhancing right temporal mass.  Given the characteristics of the MRI scan, it is highly likely that he demonstrates high-grade glioma and concerning for glioblastoma multiforme.  We have discussed in length the possible benefits of biopsy, surgical resection, medical management, as well as chemotherapy, radiation treatments, and doing nothing.  Given the high probability that the mass represents a high-grade glioma, the patient, after weighing the risks and the benefits of surgery, has agreed to undergo a surgical biopsy and resection of the mass as well as concomitant chemotherapy and radiation as the diagnosis demonstrates a high-grade glioma.  The patient has signed consent for his right temporal craniotomy for biopsy and likely resection of right temporal brain tumor.  He agrees that he will be n.p.o. after mid night on Wednesday night.  He is sent for preoperative assessment with the Anesthesiology tomorrow morning.  He has undergone vocational rehab assessment.
---
DESCRIPTION: MRI demonstrated right contrast-enhancing temporal mass.

neurology, new onset seizures, temporal mass, cerebellar exam, glioma, temporal, massNOTE

The situation involves a diagnosis of a potentially life-threatening condition, a high-grade glioma, which is significantly concerning due to its aggressive nature. Decisions about treatment, including surgery, chemotherapy, and radiation, are high-stakes as they can significantly impact the patient's survival and quality of life. The patient has to evaluate complex information and choices, potentially life-altering treatments, which represent a very serious medical scenario.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Heart Catheterization & Ventriculogram

PROCEDURE PERFORMED:,1.  Right heart catheterization.,2.  Left heart catheterization.,3.  Left ventriculogram.,4.  Aortogram.,5.  Bilateral selective coronary angiography.,ANESTHESIA:,  1% lidocaine and IV sedation including Versed 1 mg.,INDICATION:,  The patient is a 48-year-old female with severe mitral stenosis diagnosed by echocardiography, moderate aortic insufficiency and moderate to severe pulmonary hypertension who is being evaluated as a part of a preoperative workup for mitral and possible aortic valve repair or replacement.  She has had atrial fibrillation and previous episodes of congestive heart failure.  She has dyspnea on exertion and occasionally orthopnea and paroxysmal nocturnal dyspnea.,PROCEDURE:,  After the risks, benefits, and alternatives of the above-mentioned procedure were explained to the patient in detail, informed consent was obtained, both verbally and in writing.  The patient was taken to the Cardiac Catheterization Lab where the procedure was performed.  The right inguinal area was thoroughly cleansed with Betadine solution and the patient was draped in the usual manner.  1% lidocaine solution was used to anesthetize the right inguinal area.  Once adequate anesthesia had been attained, a thing wall Argon needle was used to cannulate the right femoral vein.  A guidewire was advanced into the lumen of the vein without resistance.  The needle was removed and the guidewire was secured to the sterile field.  The needle was flushed and then used to cannulate the right femoral artery.  A guidewire was advanced through the lumen of the needle without resistance.  A small nick was made in the skin and the needle was removed.  This pressure was held.  A #6 French arterial sheath was advanced over the guidewire without resistance.  The dilator and guidewire were removed.  FiO2 sample was obtained and the sheath was flushed.  An #8 French sheath was advanced over the guidewire into the femoral vein after which the dilator and guidewire were removed and the sheath was flushed.  A Swan-Ganz catheter was advanced through the venous sheath into a pulmonary capillary was positioned and the balloon was temporarily deflated.  An angulated pigtail catheter was advanced into the left ventricle under direct fluoroscopic visualization with the use of a guidewire.  The guidewire was removed.  The catheter was connected to a manifold and flushed.  Left ventricular pressures were continuously measured and the balloon was re-inflated and pulmonary capillary wedge pressure was remeasured.  Using dual transducers together and the mitral valve radius was estimated.  The balloon was deflated and mixed venous sample was obtained.  Hemodynamics were measured.  The catheter was pulled back in to the pulmonary artery right ventricle and right atrium.  The right atrial sample was obtained and was negative for shunt.  The Swan-Ganz catheter was then removed and a left ventriculogram was performed in the RAO projection with a single power injection of non-ionic contrast material.  Pullback was then performed which revealed a minimal LV-AO gradient.  Since the patient had aortic insufficiency on her echocardiogram, an aortogram was performed in the LAO projection with a single power injection of non-ionic contrast material.  The pigtail catheter was then removed and a Judkins left #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire.  The guidewire was removed.  The catheter was connected to the manifold and flushed.  The ostium of the left main coronary artery was carefully engaged.  Using multiple hand injections of non-ionic contrast material, the left coronary system was evaluated in different views.  This catheter was then removed and a Judkins right #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire.  The guidewire was removed.  The catheter was connected to the manifold and flushed.  The ostium of the right coronary artery was then engaged and using hand injections of non-ionic contrast material, the right coronary system was evaluated in different views.  This catheter was removed.  The sheaths were flushed final time.  The patient was taken to the Postcatheterization Holding Area in stable condition.,FINDINGS:,HEMODYNAMICS: , Right atrial pressure 9 mmHg, right ventricular pressure is 53/14 mmHg, pulmonary artery pressure 62/33 mmHg with a mean of 46 mmHg.  Pulmonary capillary wedge pressure is 29 mmHg.  Left ventricular end diastolic pressure was 13 mmHg both pre and post left ventriculogram.  Cardiac index was 2.4 liters per minute/m2.  Cardiac output 4.0 liters per minute.  The mitral valve gradient was 24.5 and mitral valve area was calculated to be 0.67 cm2.  The aortic valve area is calculated to be 2.08 cm2.,LEFT VENTRICULOGRAM: , No segmental wall motion abnormalities were noted.  The left ventricle was somewhat hyperdynamic with an ejection fraction of 70%.  2+ to 3+ mitral regurgitation was noted.,AORTOGRAM: , There was 2+ to 3+ aortic insufficiency noted.  There was no evidence of aortic aneurysm or dissection.,LEFT MAIN CORONARY ARTERY: , This was a moderate caliber vessel and it is rather long.  It bifurcates into the LAD and left circumflex coronary artery.  No angiographically significant stenosis is noted.,LEFT ANTERIOR DESCENDING ARTERY:,  The LAD begins as a moderate caliber vessel ________ anteriorly in the intraventricular groove.  It tapers in its mid portion to become small caliber vessel.  Luminal irregularities are present, however, no angiographically significant stenosis is noted.,LEFT CIRCUMFLEX CORONARY ARTERY: , The left circumflex coronary artery begins as a moderate caliber vessel.  Small obtuse marginal branches are noted and this is the nondominant system.  Lumen irregularities are present throughout the circumflex system.  However no angiographically significant stenosis is noted.,RIGHT CORONARY ARTERY: , This is the moderate caliber vessel and it is the dominant system.  No angiographically significant stenosis is noted, however, mild luminal irregularities are noted throughout the vessel.,IMPRESSION:,1.  Nonobstructive coronary artery disease.,2.  Severe mitral stenosis.,3.  2+ to 3+ mitral regurgitation.,4.  2+ to 3+ aortic insufficiency.
---
DESCRIPTION: Right and left heart catheterization, left ventriculogram, aortogram, and bilateral selective coronary angiography.  The patient is a 48-year-old female with severe mitral stenosis diagnosed by echocardiography, moderate aortic insufficiency and moderate to severe pulmonary hypertension who is being evaluated as a part of a preoperative workup for mitral and possible aortic valve repair or replacement.

The procedure described is complex and involves significant cardiovascular interventions such as heart catheterization and ventriculogram, which are invasive and typically performed in a cardiac catheterization lab. The patient has serious health conditions, including severe mitral stenosis, pulmonary hypertension, and previous episodes of congestive heart failure. These initial conditions elevate the stakes due to potential risks and complications, especially considering the patient is being evaluated for possible valve repair or replacement. The outcomes of this procedure will heavily influence her treatment plan, indicating a high-stakes situation.


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

Medical Specialty: Neurosurgery
Sample Name: Craniotomy - Frontal Zygomatic

PREOPERATIVE DIAGNOSIS:,  Metopic synostosis with trigonocephaly.,POSTOPERATIVE DIAGNOSIS:,  Metopic synostosis with trigonocephaly.,PROCEDURES:  ,1.  Bilateral orbital frontal zygomatic craniotomy (skull base approach).,2.  Bilateral orbital advancement with (C-shaped osteotomies down to the inferior orbital rim) with bilateral orbital advancement with bone grafts.,3.  Bilateral forehead reconstruction with autologous graft.,4.  Advancement of the temporalis muscle bilaterally.,5.  Barrel-stave osteotomies of the parietal bones.,ANESTHESIA: , General.,PROCEDURE: , After induction of general anesthesia, the patient was placed supine on the operating room table with a roll under his shoulders and his head resting on a foam doughnut.  Scalp was clipped.  He was prepped with ChloraPrep.  Incision was infiltrated with 0.5% Xylocaine with epinephrine 1:200,000 and he received antibiotics and he was then reprepped and draped in a sterile manner.,A bicoronal zigzag incision was made and Raney clips used for hemostasis.  Subcutaneous flaps were developed and reflected anteriorly and slightly posteriorly.  These were subgaleal flaps.  Bipolar and Bovie cautery were used for hemostasis.  The craniectomy was outlined with methylene blue.  The pericranium was incised exposing the bone along the outline of the craniotomy.,Paired bur holes were drilled anteriorly and posteriorly straddling the metopic suture.  One was just above the nasion and the other was near the bregma.  Also bilateral pterional bur holes were drilled.  There was a little bit of bleeding from a tributary of the sagittal sinus anteriorly and so bone wax was used for hemostasis in all the bur holes.,The dura was separated with a #4 Penfield dissector and then the craniotomies were fashioned or cut.  I should say with the Midas Rex drill using the V5 bit and the footplate attachment, the bilateral craniotomies were cut and then the midline piece was elevated separately.  Great care was taken when removing the bone from the midline.  Bipolar cautery was used for bleeding points on the dura and especially over the sagittal sinus and the bleeding was controlled.,The wound was irrigated with bacitracin irrigation.,The next step was to perform the orbital osteotomies with careful protection of the orbital contents.  Osteotomies were made with the Midas Rex drill using the V5 bit in the orbital roof bilaterally.  This was a very thick and vertically oriented orbital roof on each side.  Midas Rex drill and osteotomes and mallet were used to cut these osteotomies using retractors to protect the orbital contents and the dura.  The osteotomies were carried down through the tripod of the orbit and down through the lateral orbital rim and all the way down to the inferior orbital rim using the osteotome and mallet.  Bone wax was used for hemostasis.  It was necessary to score the undersurface of the bone at the midline because it was so thick and pointed.  So we were not going to be able to effect the orbital advancement without scoring the bone and thinning it out a bit.  This was done with the Midas Rex drill using B5 bit.  Also, the marked ridge just above the nasion was burred down with the Midas Rex drill.  The osteotomies were also carried down through the zygoma.  At this point, with a gentle rocking motion and sustained pressure using the osteotomes, it was then possible to carefully advance the orbital rims bilaterally, first on the right and then on the left again using just a careful rocking motion against the remaining bone to gently bend the orbital rims outward bilaterally.,Dr. X cut the bone grafts from the bone flaps and I fashioned a shelf to secure the bone graft by burring a ledge on the internal surface of the superior orbital rim.  This created a shelf for the notched bone graft to lean against basically anteriorly.  The posterior notch of the bone graft was able to be braced by the ledge of orbital roof posteriorly.,The left medial orbital rim greenstick fractured a bit, but the bone graft appeared to stay in place.,Holes were then cut in the supraorbital rim for advancement of the temporalis muscle and then a Synthes mesh was placed anteriorly using absorbable screw hardware and attached the mesh where the forehead bone flaps turned around and recontoured to make a nice bilateral forehead for Isaac.,At this point the undersurface of the temporalis muscle was scored using the Bovie cautery to allow advancement of the muscle anteriorly and we sutured it to the supraorbital rims bilaterally with #3-0 Vicryl suture.  This helped fill-in the indentation left by the orbital advancement at the temporal region.,Also, I separated the undersurface of the dura from the bone bilaterally and cut multiple barrel-stave osteotomies in the parietal bones and then greenstick fractured these barrel-staves outward to create a more normal contour of the bone slightly posteriorly.,At this point, Gelfoam had been used to protect the dura over the sagittal sinus during this part of the procedure.,The wound was then irrigated with bacitracin irrigation.  Bleeding had been controlled during the procedure with Bovie and bipolar electrocautery, even so the blood loss was fairly significant adding up to about 300 or 400 mL and he received that much in packed cells and he also received a unit of fresh frozen plasma.,At this point, the reconstruction looked good.  The advancement was about 1 cm and we were pleased with the results.  The wound was irrigated and then the Gelfoam over the midline dura was left in place and the galea was then closed with #4-0 and some #3-0 Vicryl interrupted suture and #5-0 mild chromic on the skin.  The patient tolerated procedure well.  No complications.  Sponge and needle counts were correct.  Again, blood loss was bout 300 to 400 mL and he received 2 units of blood and some fresh frozen plasma.
---
DESCRIPTION: Bilateral orbital frontal zygomatic craniotomy (skull base approach), bilateral orbital advancement with (C-shaped osteotomies down to the inferior orbital rim) with bilateral orbital advancement with bone grafts, bilateral forehead reconstruction with autologous graft.

neurosurgery, metopic synostosis, trigonocephaly, bilateral orbital frontal zygomatic craniotomy, skull base approach, orbital advancement, c-shaped osteotomies, forehead reconstruction, temporalis muscle, midas rex drill, frontal zygomatic, sagittal sinus, orbital roof, orbital rim, bone grafts, forehead, bone, orbital, craniotomy, osteotomies,

The situation involves a complex neurosurgical procedure, specifically a craniotomy and orbital advancement for a condition called metopic synostosis with trigonocephaly. This type of surgery is high-stakes due to the critical nature of the area being operated on (the skull and brain), the complexity of the procedure, and the potential risks involved such as significant blood loss, complications with anesthesia, and the need for precise surgical technique to avoid damaging critical structures. The outcome of the surgery can have significant implications for the patient's health and development, which further contributes to the high-stakes nature of the situation.


Medical Specialty: Surgery
Sample Name: Laparoscopic Gastric Bypass

PREOPERATIVE DIAGNOSIS: , Morbid obesity.,POSTOPERATIVE DIAGNOSIS:  ,Morbid obesity.,PROCEDURE: , Laparoscopic antecolic antegastric Roux-en-Y gastric bypass with EEA anastomosis.,ANESTHESIA: , General with endotracheal intubation.,INDICATION FOR PROCEDURE: , This is a 30-year-old female, who has been overweight for many years.  She has tried many different diets, but is unsuccessful.  She has been to our Bariatric Surgery Seminar, received some handouts, and signed the consent.  The risks and benefits of the procedure have been explained to the patient.,PROCEDURE IN DETAIL:  ,The patient was taken to the operating room and placed supine on the operating room table.  All pressure points were carefully padded.  She was given general anesthesia with endotracheal intubation.  SCD stockings were placed on both legs.  Foley catheter was placed for bladder decompression.  The abdomen was then prepped and draped in standard sterile surgical fashion.  Marcaine was then injected through umbilicus.  A small incision was made.  A Veress needle was introduced into the abdomen.  CO2 insufflation was done to a maximum pressure of 15 mmHg.  A 12-mm VersaStep port was placed through the umbilicus.  I then placed a 5-mm port just anterior to the midaxillary line and just subcostal on the right side.  I placed another 5-mm port in the midclavicular line just subcostal on the right side, a few centimeters below and medial to that, I placed a 12-mm VersaStep port.  On the left side, just anterior to the midaxillary line and just subcostal, I placed a 5-mm port.  A few centimeters below and medial to that, I placed a 15-mm port.  I began by lifting up the omentum and identifying the transverse colon and lifting that up and thereby identifying my ligament of Treitz.  I ran the small bowel down approximately 40 cm and divided the small bowel with a white load GIA stapler.  I then divided the mesentery all the way down to the base of the mesentery with a LigaSure device.  I then ran the distal bowel down, approximately 100 cm, and at 100 cm, I made a hole at the antimesenteric portion of the Roux limb and a hole in the antimesenteric portion of the duodenogastric limb, and I passed a 45 white load stapler and fired a stapler creating a side-to-side anastomosis.  I reapproximated the edges of the defect.  I lifted it up and stapled across it with another white load stapler.  I then closed the mesenteric defect with interrupted Surgidac sutures.  I divided the omentum all the way down to the colon in order to create a passageway for my small bowel to go antecolic.  I then put the patient in reverse Trendelenburg.  I placed a liver retractor, identified, and dissected the angle of His.  I then dissected on the lesser curve, approximately 2.5 cm below the gastroesophageal junction, and got into a lesser space.  I fired transversely across the stomach with a 45 blue load stapler.  I then used two fires of the 60 blue load with SeamGuard to go up into my angle of His, thereby creating my gastric pouch.  I then made a hole at the base of the gastric pouch and had Anesthesia remove the bougie and place the OG tube connected to the anvil.  I pulled the anvil into place, and I then opened up my 15-mm port site and passed my EEA stapler.  I passed that in the end of my Roux limb and had the spike come out antimesenteric.  I joined the spike with the anvil and fired a stapler creating an end-to-side anastomosis, then divided across the redundant portion of my Roux limb with a white load GI stapler, and removed it with an Endocatch bag.  I put some additional 2-0 Vicryl sutures in the anastomosis for further security.  I then placed a bowel clamp across the bowel.  I went above and passed an EGD scope into the mouth down to the esophagus and into the gastric pouch.  I distended gastric pouch with air.  There was no air leak seen.  I could pass the scope easily through the anastomosis.  There was no bleeding seen through the scope.  We closed the 15-mm port site with interrupted 0 Vicryl suture utilizing Carter-Thomason.  I copiously irrigated out that incision with about 2 L of saline.  I then closed the skin of all incisions with running Monocryl.  Sponge, instrument, and needle counts were correct at the end of the case.  The patient tolerated the procedure well without any complications.
---
DESCRIPTION: Morbid obesity.  Laparoscopic antecolic antegastric Roux-en-Y gastric bypass with EEA anastomosis.  This is a 30-year-old female, who has been overweight for many years.  She has tried many different diets, but is unsuccessful.

surgery, gastric bypass, eea anastomosis, roux-en-y, antegastric, antecolic, morbid obesity, roux limb, gastric pouch, intubation, laparoscopic, bypass, roux, endotracheal, anastomosis, gastric

The situation involves a description of a laparoscopic gastric bypass surgery, a major surgical procedure. This type of surgery is typically performed to treat morbid obesity and involves significant health improvements but also carries risks, making it a high-stakes situation. The surgery described includes detailed procedural steps and checks for complications, indicating the critical nature of the operation. Given the potential impact on the patient's health and the technical complexity of the procedure, it is considered high-stakes.


Medical Specialty: Surgery
Sample Name: Carpal Tunnel Release - 1

PREOPERATIVE DIAGNOSIS: , Right carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS: , Right carpal tunnel syndrome.,TITLE OF THE PROCEDURE: , Right carpal tunnel release.,COMPLICATIONS:,  There were no complications during the procedure.,SPECIMEN:  ,The specimen was sent to pathology.,INSTRUMENTS: , All counts were correct at the end of the case and no complications were encountered.,INDICATIONS:  ,This is a 69-year-old female who have been complaining of right hand pain, which was steadily getting worse over a prolonged period of time.  The patient had tried nonoperative therapy, which did not assist the patient.  The patient had previous diagnosis of carpal tunnel and EMG showed compression of the right median nerve.  As a result of these findings, the patient was sent to my office presenting with this history and was carefully evaluated.  On initial evaluation, the patient had the symptomology of carpal tunnel syndrome.  The patient at the time had the risks, benefits, and alternatives thoroughly explained to her.  All questions were answered.  No guarantees were given.  The patient had agreed to the surgical procedure and the postoperative rehabilitation as needed.,DETAILS OF THE PROCEDURE:  ,The patient was brought to the operating room, placed supine on the operating room table, prepped and draped in the sterile fashion and was given sedation.  The patient was then given sedation.  Once this was complete, the area overlying the carpal ligament was carefully injected with 1% lidocaine with epinephrine.  The patient had this area carefully and thoroughly injected with approximately 10 mL of lidocaine with epinephrine and once this was complete, a 15-blade knife was then used to incise the skin opposite the radial aspect of the fourth ray.  Careful dissection under direct visualization was performed through the subcutaneous fat as well as through the palmar fascia.  A Weitlaner retractor was then used to retract the skin and careful dissection through the palmar fascia would then revealed the transverse carpal ligament.  This was then carefully incised using a 15-blade knife and once entry was again into the carpal canal, a Freer elevator was then inserted and under direct visualization, the carpal ligament was then released.  The transverse carpal ligament was carefully released first in the distal direction until palmar fat could be visualized and by palpation no further ligament could be felt.  The area was well hemostased with the 1% lidocaine with epinephrine and both proximal and distal dissection along the nerve was performed.  Visualization of the transverse carpal ligament was maintained with Weitlaner retractor as well as centric.  Both the centric and the Ragnell were used to retract both proximal and distal corners of the incision and the entirety of the area was under direct visualization at all times.  Palmar fascia was released both proximally and distally as well as the transverse carpal ligament.  Direct palpation of the carpal canal demonstrated a full and complete release.  Observation of the median nerve revealed an area of hyperemia in the distal two-thirds of the nerve, which demonstrated the likely area of compression.  Once this was complete, hemostasis was established using bipolar cautery and some small surface bleeders and irrigation of the area was performed and then the closure was achieved with 4-0 chromic suture in a horizontal mattress and interrupted stitch.  Xeroform was then applied to the incision.  A bulky dressing was then applied consisting of Kerlix and Ace wrap, and the patient was taken to the recovery room in stable condition without any complications.
---
DESCRIPTION: Right carpal tunnel release.

Right carpal tunnel release.

surgery, carpal tunnel syndrome, ace wrap, emg, freer elevator, kerlix, weitlaner retractor, bulky dressing, carpal tunnel, carpal tunnel release, palmar fascia, subcutaneous fat, lidocaine with epinephrine, transverse carpal ligament, carpal ligament, carpal, tunnel, ligament,

The situation involves a surgical procedure for carpal tunnel release, which is generally considered a routine and low-risk surgery. The procedure was completed without complications, and the patient was in stable condition afterward. While all surgeries carry some degree of risk, this particular type is not considered high-stakes compared to other more invasive or emergency surgeries.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Breast Ultrasound & Biopsy

EXAM:  ,Bilateral diagnostic mammogram, left breast ultrasound and biopsy.,HISTORY: , 30-year-old female presents for digital bilateral mammography secondary to a soft tissue lump palpated by the patient in the upper right shoulder.  The patient has a family history of breast cancer within her mother at age 58.  Patient denies personal history of breast cancer.,TECHNIQUE AND FINDINGS:  ,Craniocaudal and mediolateral oblique projections of bilateral breasts were obtained on mm/dd/yy.  An additional lateromedial projection of the right breast was obtained.  The breasts demonstrate heterogeneously-dense fibroglandular tissue.  Within the upper outer aspect of the left breast, there is evidence of a circumscribed density measuring approximately 1 cm x 0.7 cm in diameter.  No additional dominant mass, areas of architectural distortion, or malignant-type calcifications are seen.  Multiple additional benign-appearing calcifications are visualized bilaterally.  Skin overlying both breasts is unremarkable.,Bilateral breast ultrasound was subsequently performed, which demonstrated an ovoid mass measuring approximately 0.5 x 0.5 x 0.4 cm in diameter located within the anteromedial aspect of the left shoulder.  This mass demonstrates isoechoic echotexture to the adjacent muscle, with no evidence of internal color flow.  This may represent benign fibrous tissue or a lipoma.,Additional ultrasonographic imaging of the left breast demonstrates a complex circumscribed solid and cystic lesion with hypervascular properties at the 2 o'clock position, measuring 0.7 x 0.7 x 0.8 cm in diameter.  At this time, the lesion was determined to be amenable by ultrasound-guided core biopsy.,The risks and complications of the procedure were discussed with the patient for biopsy of the solid and cystic lesion of the 2 o'clock position of the left breast.  Informed consent was obtained.  The lesion was re-localized under ultrasound guidance.  The left breast was prepped and draped in the usual sterile fashion.  2% lidocaine was administered locally for anesthesia.  Additional lidocaine with epinephrine was administered around the distal aspect of the lesion.  A small skin nick was made.  Color Doppler surrounding the lesion demonstrates multiple vessels surrounding the lesion at all sides.  The lateral to medial approach was performed with an 11-gauge Mammotome device.  The device was advanced under ultrasound guidance, with the superior aspect of the lesion placed within the aperture.  Two core biopsies were obtained.  The third core biopsy demonstrated evidence of an expanding hypoechoic area surrounding the lesion, consistent with a rapidly-expanding hematoma.  Arterial blood was visualized exiting the access site.  A biopsy clip was attempted to be placed, however could not be performed secondary to the active hemorrhage.  Therefore, the Mammotome was removed, and direct pressure over the access site and biopsy location was applied for approximately 20 minutes until hemostasis was achieved.  Postprocedural imaging of the 2 o'clock position of the left breast demonstrates evidence of a hematoma measuring approximately 1.9 x 4.4 x 1.3 cm in diameter.  The left breast was re-cleansed with a ChloraPrep, and a pressure bandage and ice packing were applied to the left breast.  The patient was observed in the ultrasound department for the following 30 minutes without complaints.  The patient was subsequently discharged with information and instructions on utilizing the ice bandage.  The obtained specimens were sent to pathology for further analysis.,IMPRESSION:,1.  A mixed solid and cystic lesion at the 2 o'clock position of the left breast was accessed under ultrasound guidance utilizing a Mammotome core biopsy instrument, and multiple core biopsies were obtained.  Transient arterial hemorrhage was noted at the biopsy site, resulting in a localized 4 cm hematoma.  Pressure was applied until hemostasis was achieved.  The patient was monitored for approximately 30 minutes after the procedure, and was ultimately discharged in good condition.  The core biopsies were submitted to pathology for further analysis.,2.  Small isoechoic ovoid mass within the anteromedial aspect of the left shoulder does not demonstrate color flow, and likely represents fibrotic changes or a lipoma.,3.  Suspicious mammographic findings.  The circumscribed density measuring approximately 8 mm at the 2 o'clock position of the left breast was subsequently biopsied.  Further pathologic analysis is pending.,BIRADS Classification 4 - Suspicious findings.,MAMMOGRAPHY INFORMATION:,1.  A certain percentage of cancers, probably 10% to 15%, will not be identified by mammography.,2.  Lack of radiographic evidence of malignancy should not delay a biopsy if a clinically suspicious mass is present.,3.  These images were obtained with FDA-approved digital mammography equipment, and iCAD SecondLook Software Version 7.2 was utilized.
---
DESCRIPTION: Diagnostic mammogram, full-field digital, ultrasound of the breast and mammotome core biopsy of the left breast.

obstetrics / gynecology, mammotome core biopsy, diagnostic mammogram, breast cancer, bilateral breasts, circumscribed density, ovoid mass, breast ultrasound, core biopsy, lesion, biopsy, breast, hematoma, mammotome, mammography, ultrasound,

The situation involves a breast ultrasound and biopsy being performed on a young woman with a palpable lump and a family history of breast cancer. The presentation of a suspicious finding in the breast requires a biopsy to rule out or confirm malignancy, which is high-stakes due to the potential implications for the patient's health. The biopsy procedure resulted in a complication (arterial hemorrhage and hematoma), elevating the stakes due to immediate concerns over patient safety and the need for careful management. The BIRADS classification indicates that the imaging findings are suspicious for malignancy, which further heightens the stakes as it necessitates careful follow-up and potentially significant medical intervention. The outcome of the pathology will have critical implications for her treatment and prognosis.


Medical Specialty: Hematology - Oncology
Sample Name: Anemia - Consult

DIAGNOSIS:,  Refractory anemia that is transfusion dependent.,CHIEF COMPLAINT: , I needed a blood transfusion.,HISTORY: , The patient is a 78-year-old gentleman with no substantial past medical history except for diabetes.  He denies any comorbid complications of the diabetes including kidney disease, heart disease, stroke, vision loss, or neuropathy.  At this time, he has been admitted for anemia with hemoglobin of 7.1 and requiring transfusion.  He reports that he has no signs or symptom of bleeding and had a blood transfusion approximately two months ago and actually several weeks before that blood transfusion, he had a transfusion for anemia.  He has been placed on B12, oral iron, and Procrit.  At this time, we are asked to evaluate him for further causes and treatment for his anemia.  He denies any constitutional complaints except for fatigue, malaise, and some dyspnea.  He has no adenopathy that he reports.  No fevers, night sweats, bone pain, rash, arthralgias, or myalgias.,PAST MEDICAL HISTORY:  ,Diabetes.,PAST SURGICAL HISTORY:,  Hernia repair.,ALLERGIES: , He has no allergies.,MEDICATIONS: , Listed in the chart and include Coumadin, Lasix, metformin, folic acid, diltiazem, B12, Prevacid, and Feosol.,SOCIAL HISTORY: , He is a tobacco user.  He does not drink.  He lives alone, but has family and social support to look on him.,FAMILY HISTORY:,  Negative for blood or cancer disorders according to the patient.,PHYSICAL EXAMINATION:,GENERAL:  He is an elderly gentleman in no acute distress.  He is sitting up in bed eating his breakfast.  He is alert and oriented and answering questions appropriately.,VITAL SIGNS:  Blood pressure of 110/60, pulse of 99, respiratory rate of 14, and temperature of 97.4.  He is 69 inches tall and weighs 174 pounds.,HEENT:  Sclerae show mild arcus senilis in the right.  Left is clear.  Pupils are equally round and reactive to light.  Extraocular movements are intact.  Oropharynx is clear.,NECK:  Supple.  Trachea is midline.  No jugular venous pressure distention is noted.  No adenopathy in the cervical, supraclavicular, or axillary areas.,CHEST:  Clear.,HEART:  Regular rate and rhythm.,ABDOMEN:  Soft and nontender.  There may be some fullness in the left upper quadrant, although I do not appreciate a true spleen with inspiration.,EXTREMITIES:  No clubbing, but there is some edema, but no cyanosis.,NEUROLOGIC:  Noncontributory.,DERMATOLOGIC:  Noncontributory.,CARDIOVASCULAR:  Noncontributory.,IMPRESSION: , At this time is refractory anemia, which is transfusion dependent.  He is on B12, iron, folic acid, and Procrit.  There are no sign or symptom of blood loss and a recent esophagogastroduodenoscopy, which was negative.  His creatinine was 1.  My impression at this time is that he probably has an underlying myelodysplastic syndrome or bone marrow failure.  His creatinine on this hospitalization was up slightly to 1.6 and this may contribute to his anemia.,RECOMMENDATIONS:  ,At this time, my recommendation for the patient is that he undergoes further serologic evaluation with reticulocyte count, serum protein, and electrophoresis, LDH, B12, folate, erythropoietin level, and he should undergo a bone marrow aspiration and biopsy.  I have discussed the procedure in detail which the patient.  I have discussed the risks, benefits, and successes of that treatment and usefulness of the bone marrow and predicting his cause of refractory anemia and further therapeutic interventions, which might be beneficial to him.  He is willing to proceed with the studies I have described to him.  We will order an ultrasound of his abdomen because of the possible fullness of the spleen, and I will probably see him in follow up after this hospitalization.,As always, we greatly appreciate being able to participate in the care of your patient.  We appreciate the consultation of the patient.
---
DESCRIPTION: Refractory anemia that is transfusion dependent.  At this time, he has been admitted for anemia with hemoglobin of 7.1 and requiring transfusion.

The situation involves a 78-year-old patient with refractory anemia that is transfusion-dependent, a condition that requires continuous medical attention and management. The anemia's refractoriness, along with the patient's age and existing medical condition (diabetes), makes this a high-stakes situation. Timely and precise diagnosis, possibly involving myelodysplastic syndromes or bone marrow failure, as well as subsequent management and treatment plans, are critical for the patient's quality of life and survival. While there is no immediate life-threatening emergency, the long-term implications of mismanagement or delayed diagnosis could severely impact the patient's health. Therefore, this consultation has significant importance in guiding the future care plan for the patient.


Medical Specialty: Gastroenterology
Sample Name: Thoracotomy & Esophageal Exploration

PREOPERATIVE DIAGNOSIS:  ,Esophageal rupture.,POSTOPERATIVE DIAGNOSIS:,  Esophageal rupture.,OPERATION PERFORMED,1.  Left thoracotomy with drainage of pleural fluid collection.,2.  Esophageal exploration and repair of esophageal perforation.,3.  Diagnostic laparoscopy and gastrostomy.,4.  Radiographic gastrostomy tube study with gastric contrast, interpretation.,ANESTHESIA: , General anesthesia.,INDICATIONS OF THE PROCEDURE: , The patient is a 47-year-old male with a history of chronic esophageal stricture who is admitted with food sticking and retching.  He has esophageal rupture on CT scan and comes now for a thoracotomy and gastrostomy.,DETAILS OF THE PROCEDURE: , After an extensive informed consent discussion process, the patient was brought to the operating room.  He was placed in a supine position on the operating table.  After induction of general anesthesia and placement of a double lumen endotracheal tube, he was turned and placed in a right lateral decubitus position on a beanbag with appropriate padding and axillary roll.  Left chest was prepped and draped in a usual sterile fashion.  After administration of intravenous antibiotics, a left thoracotomy incision was made, dissection was carried down to the subcutaneous tissues, muscle layers down to the fifth interspace.  The left lung was deflated and the pleural cavity entered.  The Finochietto retractor was used to help provide exposure.  The sixth rib was shingled in the posterior position and a careful expiration of the left pleural cavity was performed.,Immediately encountered was left pleural fluid including some purulent fluid.  Cultures of this were sampled and sent for microbiology analysis.  The left pleural space was then copiously irrigated.  A careful expiration demonstrated that the rupture appeared to be sealed.  There was crepitus within the mediastinal cavity.  The mediastinum was opened and explored and the esophagus was explored.  The tissues of the esophagus appeared to show some friability and an area of the rupture in the distal esophagus.  It was not possible to place any stitches in this tissue and instead a small intercostal flap was developed and placed to cover the area.  The area was copiously irrigated, this provided nice coverage and repair.  After final irrigation and inspection, two chest tubes were placed including a #36 French right angled tube at the diaphragm and a posterior straight #36 French.  These were secured at the left axillary line region at the skin level with #0-silk.,The intercostal sutures were used to close the chest wall with a #2 Vicryl sutures.  Muscle layers were closed with running #1 Vicryl sutures.  The wound was irrigated and the skin was closed with skin staples.,The patient was then turned and placed in a supine position.  A laparoscopic gastrostomy was performed and then a diagnostic laparoscopy performed.  A Veress needle was carefully inserted into the abdomen, pneumoperitoneum was established in the usual fashion, a bladeless 5-mm separator trocar was introduced.  The laparoscope was introduced.  A single additional left-sided separator trocar was introduced.  It was not possible to safely pass a nasogastric or orogastric tube, pass the stricture and perforation and so the nasogastric tube was left right at the level where there was some stricture or narrowing or resistance.  The stomach however did have some air insufflation and we were able to place our T-fasteners through the anterior abdominal wall and through the anterior gastric wall safely.  The skin incision was made and the gastric lumen was then accessed with the Seldinger technique.  Guide wire was introduced into the stomach lumen and series of dilators was then passed over the guide wire.  #18 French Gastrostomy was then passed into the stomach lumen and the balloon was inflated.  We confirmed that we were in the gastric lumen and the balloon was pulled up, creating apposition of the gastric wall and the anterior abdominal wall.  The T-fasteners were all crimped and secured into position.  As was in the plan, the gastrostomy was secured to the skin and into the tube.  Sterile dressing was applied.  Aspiration demonstrated gastric content.,Gastrostomy tube study, with interpretation.  Radiographic gastrostomy tube study with gastric contrast, with
---
DESCRIPTION: Left thoracotomy with drainage of pleural fluid collection, esophageal exploration and repair of esophageal perforation, diagnostic laparoscopy and gastrostomy, and radiographic gastrostomy tube study with gastric contrast, interpretation.

gastroenterology, esophageal rupture, thoracotomy, drainage of pleural fluid, esophageal perforation, esophageal exploration, laparoscopy, gastrostomy, pleural fluid, diagnostic laparoscopy, radiographic gastrostomy, gastric lumen, gastrostomy tube, gastric contrast, gastric, interpretation, abdominal, pleural, lumen, esophageal, tube,

The situation describes a complex surgical procedure involving an esophageal rupture, which is a critical condition that necessitates immediate intervention to prevent severe complications, such as infection or sepsis. The patient's current state and the nature of the surgery make it a high-stakes situation since the success of the operation and the patient's recovery are crucial. Furthermore, the procedure involves potential complications that could have significant implications on the patient's health and well-being.


Medical Specialty: Sleep Medicine
Sample Name: Video EEG - 3

PROCEDURE: , EEG during wakefulness demonstrates background activity consisting of moderate-amplitude beta activity seen bilaterally.  The EEG background is symmetric.  Independent, small, positive, sharp wave activity is seen in the frontotemporal regions bilaterally with sharp-slow wave discharges seen more predominantly in the right frontotemporal head region.  No clinical signs of involuntary movements are noted during synchronous video monitoring.  Recording time is 22 minutes and 22 seconds.  There is attenuation of the background, faster activity during drowsiness and some light sleep is recorded.  No sustained epileptogenic activity is evident, but the independent bilateral sharp wave activity is seen intermittently.  Photic stimulation induced a bilaterally symmetric photic driving response.,IMPRESSION:,  EEG during wakefulness and light sleep is abnormal with independent, positive sharp wave activity seen in both frontotemporal head regions, more predominant in the right frontotemporal region.  The EEG findings are consistent with potentially epileptogenic process.  Clinical correlation is warranted.
---
DESCRIPTION: EEG during wakefulness and light sleep is abnormal with independent, positive sharp wave activity seen in both frontotemporal head regions, more predominant in the right frontotemporal region.

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

The situation involves interpretation of an EEG, which is critical in diagnosing neurological conditions, such as epilepsy. The presence of abnormal sharp wave activity suggests a potentially epileptogenic process, meaning it could be related to seizure activity. This has significant implications for the patient's health and treatment, making it high-stakes. Accurate diagnosis is essential to prescribe appropriate treatment and manage the condition, highlighting the importance and urgency of this analysis.


Medical Specialty: Orthopedic
Sample Name: Hardware Removal - Elbow

PREOPERATIVE DIAGNOSIS: , Retained hardware in left elbow.,POSTOPERATIVE DIAGNOSIS:,  Retained hardware in left elbow.,PROCEDURE: , Hardware removal in the left elbow.,ANESTHESIA: , Procedure done under general anesthesia.  The patient also received 4 mL of 0.25% Marcaine of local anesthetic.,TOURNIQUET:  ,There is no tourniquet time.,ESTIMATED BLOOD LOSS:  ,Minimal.,COMPLICATIONS:  ,No intraoperative complications.,HISTORY AND PHYSICAL:  ,The patient is a 5-year, 8-month-old male who presented to me direct from ED with distracted left lateral condyle fracture.  He underwent screw compression for the fracture in October 2007.  The fracture has subsequently healed and the patient presents for hardware removal.  The risks and benefits of surgery were discussed.  The risks of surgery include the risk of anesthesia, infection, bleeding, changes in sensation and motion of extremity, failure of removal of hardware, failure to relieve pain or improved range of motion.  All questions were answered and the family agreed to the above plan.,PROCEDURE: , The patient was taken to the operating room, placed supine on the operating table.  General anesthesia was then administered.  The patient's left upper extremity was then prepped and draped in standard surgical fashion.  Using his previous incision, dissection was carried down through the screw.  A guide wire was placed inside the screw and the screw was removed without incident.  The patient had an extension lag of about 15 to 20 degrees.  Elbow is manipulated and his arm was able to be extended to zero degrees dorsiflex.  The washer was also removed without incident.  Wound was then irrigated and closed using #2-0 Vicryl and #4-0 Monocryl.  Wound was injected with 0.25% Marcaine.  The wound was then dressed with Steri-Strips, Xeroform, 4 x4 and bias.  The patient tolerated the procedure well and subsequently taken to the recovery in stable condition.,DISCHARGE NOTE: , The patient will be discharged on date of surgery.  He is to follow up in one week's time for a wound check.  This can be done at his primary care physician's office.  The patient should keep his postop dressing for about 4 to 5 days.  He may then wet the wound, but not scrub it.  The patient may resume regular activities in about 2 weeks.  The patient was given Tylenol with Codeine 10 mL p.o. every 3 to 4 hours p.r.n.
---
DESCRIPTION: Hardware removal in the left elbow.

Hardware removal in the left elbow.

orthopedic, retained hardware, hardware removal, tourniquet, elbow, hardware,

The described procedure involves the removal of previously inserted hardware from the elbow of a young child. It is a routine orthopedic procedure that carries usual surgical risks such as anesthesia, infection, and potential complications related to movement or sensation. However, there were no complications during the surgery, estimated blood loss was minimal, and the patient is expected to recover and resume normal activities within a couple of weeks. Although all surgeries carry some level of risk, this scenario is more routine and not life-threatening.