Medical Specialty: Surgery
Sample Name: Culdoplasty & Vaginal Hysterectomy

PREOPERATIVE DIAGNOSES:,1.  Chronic pelvic inflammatory disease.,2.  Pelvic adhesions.,3.  Pelvic pain.,4.  Fibroid uterus.,5.  Enterocele.,POSTOPERATIVE DIAGNOSES:,1.  Chronic pelvic inflammatory disease.,2.  Pelvic adhesions.,3.  Pelvic pain.,4.  Fibroid uterus.,5.  Enterocele.,PROCEDURE PERFORMED:,1.  Laparoscopic assisted vaginal hysterectomy, bilateral salpingo-oophorectomy.,2.  McCall's culdoplasty.,3.  Cystoscopy.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS: , 350 cc.,INDICATIONS:  ,The patient is a 45-year-old Caucasian female with complaints of long standing pelvic pain throughout the menstrual cycle and worse with menstruation, uncontrolled with Anaprox DS also with complaints of dyspareunia.  On laparoscopy in May of 2003, PID, adenomyosis, and uterine fibroids were demonstrated.  The patient desires definitive treatment.,FINDINGS AT THE TIME OF SURGERY:  ,Uterus was retroverted and somewhat boggy on bimanual examination without any palpable adnexal abnormalities.  On laparoscopic examination, the uterus was quite soft and boggy consistent with the uterine adenomyosis.  There was also evidence of fibroid change in the right fundal aspect of the uterus.  There was a white exudative material covering the uterus as well as bilateral ovaries and fallopian tubes.  There were filmy adhesions to the right pelvic side wall, as well as left pelvic side wall.,PROCEDURE: , The patient taken to the operative suite where anesthesia was found to be adequate.  She was then prepared and draped in the normal sterile fashion.  A Foley catheter was initially placed and was noted to be draining clear to yellow urine.  A weighted speculum was placed in the patient's vagina.  The bladder was elevated and the anterior lip of the cervix was grasped with a vulsellum tenaculum.  The uterus sounded to 7 cm and the cervix was then progressively dilated.  A #20 Hank dilator, which was left within the cervix used in conjunction with the vulsellum tenaculum as a uterine manipulator.  At this time, after the gloves were changed, attention was then turned to the patient's abdomen.  A small approximately 1 cm infraumbilical incision was made with the scalpel.  A Veress needle was then inserted through this incision and a pneumoperitoneum was created with CO2 gas with appropriate volumes and pressures.  A #10 mm step trocar was then inserted through this site and intraabdominal placing was confirmed with the laparoscope.  On entrance into the patient's abdomen and pelvis, survey of the abdomen and pelvis revealed the operative area to be relatively free of adhesions except for the right pelvic saddle in which there were filmy adhesions.  There was also white exudate noted covering the surface of the uterus and adnexa and the uterus had a quite boggy appearance.  At this time, under transillumination in the left anterior axillary line, a second incision was made with a scalpel and through this site a #12 mm step trocar was inserted under direct visualization by the laparoscope.  A third incision was made in the right anterior axillary line under transillumination and through this site a second #12 mm step trocar was placed under direct visualization by the laparoscope.  Then 2 cm above the pubic symphysis in the midline and fourth incision was made and a #5 mm step trocar was inserted through this site.  The uterus was elevated and deviated to the patient's right and infundibulopelvic ligament on the left was placed on tension with the aid of a grasper.  The Endo-GIA was placed through the left sided port and was fired was to cross the infundibulopelvic ligament and down passed to the level of the round ligament, transecting and stapling at the same time.  Attention was then turned to the right adnexa.,The uterus was brought over to the patient's left and the right infundibulopelvic ligament was placed on tension with the aid of a grasper.  An Endo-GIA was used to transect and staple this vasculature and down passed to the level of round ligament.  At this time, there was noted to be a small remnant of the round ligament on the right and a Harmonic scalpel was used to complete the transection and was found to be hemostatic.  In addition, on the left the same procedure was performed to completely transect the round ligament on the left and a good hemostasis was noted.  At this time, the uterus was dropped and the vesicouterine peritoneum was grasped with graspers.  The bladder was then dissected off of the lower uterine segment with the aid of a Harmonic scalpel and hemostasis was appreciated.  The anterior cervix of the uterus was scored in the midline up to the level of the fundus with the aid of a Harmonic scalpel and then out to the adnexa bilaterally to aid in orientation during the vaginal portion of the procedure.  At this time, copious suction irrigation was performed and the operative sites were found to be hemostatic.  The pneumoperitoneum was the evacuated and the attention was then turned to the vaginal portion of the procedure.  The weighted speculum was placed into the patient's vagina.  At this time, the Foley catheter was noted to have ________ and there was noted to be a small puncture site noted into the Foley bulb.  The Foley catheter was replaced and the bladder was to be filled at a later time with methylene blue to rule out any bladder injury during the laparoscopic part of the procedure.  The cervix was then grasped from right to left with a Lahey clamps and the anterior vaginal mucosa was placed on stretch with aid of Allis clamps.  The vaginal mucosa anteriorly was then incised with aid of a scalpel from the 9 o'clock position to 3 o'clock position.  The anterior vaginal mucosa and bladder were suctioned and were then dissected away from the lower uterine segment with the aid of Mayo scissors and blunt dissection until anteriorly the peritoneal cavity was entered at which time the peritoneal incision was extended bluntly.  Next, using Lahey clamps serially following the ________ placed by the Harmonic scalpel from above were followed up to the pubic uterine fundus until the uterus was delivered into the vagina anteriorly.  At this time, two curved Heaney clamps were placed across the uterine artery on the right.  This was then transected and suture ligated with #0 Vicryl suture.  The second clamp was advanced to incorporate the cardinal ligament complex and this was then transected and suture ligated with #0 Vicryl suture.  Attention was then turned to the left uterine artery which was again doubly clamped with curved Heaney clamps, transected and suture ligated with #0 Vicryl suture.  This second clamp was then advanced to capture the vasculature and the cardinal ligament complex.  This was again transected and suture ligated with #0 Vicryl suture.,Next, the uterosacral were clamped off with the curved Heaney clamps and this clamp was met in the midline by another clamp just underneath the cervix and clamping off of the vaginal cuff.  Next the uterus, ovaries and cervix were transected away from the vaginal cuff with the aid of double pointed scissors and this specimen was handed off to pathology.  At this time, the bladder was instilled with approximately 800 cc of methylene blue and there was no evidence of any leak of blue dye as could be seen from the prospective of the vaginal portion of the procedure.  Next, the posterior vaginal cuff and posterior peritoneum were incorporated in a running lock stitch of #0 Chromic beginning at the 9'o clock position over to the 3'o clock position.  Next, the anterior vaginal mucosa was grasped with the Allis clamp and the peritoneum was identified anteriorly.  The angles of the vaginal cuff were then closed with #0 Chromic suture figure-of-eight stitch with care taken to incorporate the anterior vaginal mucosa, the anterior peritoneum, and the previously closed posterior vaginal mucosa and the posterior peritoneum.  Two additional sutures medially were placed and these were tagged and not tied in place.  A #0 Vicryl suture on a UR6 needle was used to perform the McCall's culdoplasty type approximation with the vaginal cuff to open and the uterosacral ligament visualized.  This was then tied in place and the remainder of the vaginal cuff was closed with #0 Chromic suture with figure-of-eight stitches.  At this time, the gloves were changed and attention was returned to the laparoscopic portion of the procedure at which time the abdomen was re-insufflated and the patient was placed in Trendelenburg.  The bowel was moved out of the way and copious suction irrigation was performed and all operative areas were noted to be hemostatic.  The bladder was again filled with approximately 400 cc methylene blue and from the laparoscopic ________ point there was no evidence of leakage of blue dye at this time.  The pneumoperitoneum was then evacuated and a cystoscopy was performed filling the bladder with approximately 400 cc of normal saline and there was noted to be a pinpoint perforation right on bladder dome which was found to be hemostatic and was not found to have any leakage at this time.  The bladder was then drained and the Foley catheter was replaced and after gloves changed, attention was turned to the abdomen with the laparoscopic instruments removed from the patient's abdomen.  The skin incisions were closed with #4-0 undyed Vicryl in a subcuticular fashion.  Approximately 10 cc of 0.25% Marcaine in total were injected at incision site for additional analgesia.  The Steri-Strips were placed.  The patient tolerated the procedure well and taken to recovery in stable condition.  Sponge, lap, and needle counts were correct x2.  The specimens include the uterus, cervix, bilateral ovaries, and fallopian tubes.  The patient will have her Foley catheter maintained for approximately 7 to 10 days.
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DESCRIPTION: Laparoscopic assisted vaginal hysterectomy, bilateral salpingo-oophorectomy, culdoplasty, and cystoscopy.  Chronic pelvic inflammatory disease, pelvic adhesions, pelvic pain, fibroid uterus, and enterocele.

surgery, pelvic inflammatory disease, pelvic adhesions, pelvic pain, fibroid uterus, enterocele, salpingo-oophorectomy, mccall's culdoplasty, cystoscopy, laparoscopic assisted vaginal hysterectomy, foley catheter, vaginal mucosa, vaginal cuff, bladder, ligament, clamps, suture, pelvic, uterus, vaginal, inflammatory, laparoscopic,

The described scenario involves a complex surgical procedure with multiple steps and significant potential for complications, such as blood loss and inadvertent injury to surrounding structures like the bladder. This procedure addresses critical health issues including chronic pelvic inflammatory disease, fibroid uterus, and pelvic pain. The potential for complications, especially given the postoperative management of a Foley catheter for up to 10 days, indicates a high-stakes situation. Surgical outcomes can significantly affect the patient's quality of life and health status.


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Medical Specialty: Obstetrics / Gynecology
Sample Name: Tubal Ligation - Laparoscopic

PREOPERATIVE DIAGNOSIS:,  Desires permanent sterilization.,POSTOPERATIVE DIAGNOSIS: , Desires permanent sterilization.,PROCEDURE: , Laparoscopic tubal ligation, Falope ring method.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , 10 mL.,COMPLICATIONS: , None.,INDICATIONS FOR SURGERY:  ,A 35-year-old female, P4-0-0-4, who desires permanent sterilization.  The risks of bleeding, infection, damage to other organs, and subsequent ectopic pregnancy was explained.  Informed consent was obtained.,OPERATIVE FINDINGS: , Normal appearing uterus and adnexa bilaterally.,DESCRIPTION OF PROCEDURE: , After administration of general anesthesia, the patient was placed in the dorsal lithotomy position, and prepped and draped in the usual sterile fashion.  The speculum was placed in the vagina, the cervix was grasped with the tenaculum, and a uterine manipulator inserted.  This area was then draped off the remainder of the operative field.,A 5-mm incision was made umbilically after injecting 0.25% Marcaine, 2 mL.  A Veress needle was inserted to confirm an opening pressure of 2 mmHg.  Approximately 4 liters of CO2 gas was insufflated into the abdominal cavity.  The Veress needle was removed, and a 5-mm port placed.  Position was confirmed using a laparoscope.  A second port was placed under direct visualization, 3 fingerbreadths suprapubically, 7 mm in diameter, after 2 mL of 0.25% Marcaine was injected.  This was done under direct visualization.  The pelvic cavity was examined with the findings as noted above.  The Falope rings were then applied to each tube bilaterally.  Good segments were noted to be ligated.  The accessory port was removed.  The abdomen was deflated.  The laparoscope and sheath was removed.  The skin edges were approximated with 5-0 Monocryl suture in subcuticular fashion.  The instruments were removed from the vagina.  The patient was returned to the supine position, recalled from anesthesia, and transferred to the recovery room in satisfactory condition.  Sponge and needle counts correct at the conclusion of the case.  Estimated blood loss was minimal.
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DESCRIPTION: Desires permanent sterilization.  Laparoscopic tubal ligation, Falope ring method.  Normal appearing uterus and adnexa bilaterally.

obstetrics / gynecology, tenaculum, uterine manipulator, veress needle, tubal ligation, permanent sterilization, uterus, adnexa, cavity, laparoscope, laparoscopic, needle, sterilization

The situation described is a routine surgical procedure for permanent sterilization through laparoscopic tubal ligation using the Falope ring method. While surgery always carries some level of risk, this procedure is standard practice for individuals seeking permanent sterilization and is generally considered low-risk with minimal complications. All indications are that the procedure went smoothly, with minimal blood loss and no complications reported. The stakes are relatively low from a medical perspective given the absence of complications and the routine nature of the procedure.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Orthopedic
Sample Name: Carpal Tunnel Release - 5

PREOPERATIVE DIAGNOSIS:  ,Carpal tunnel syndrome, bilateral.,POSTOPERATIVE DIAGNOSIS: , Carpal tunnel syndrome, bilateral.,ANESTHESIA:,  General,NAME OF OPERATION: , Bilateral open carpal tunnel release.,FINDINGS AT OPERATION: , The patient had identical, very thick, transverse carpal ligaments, with dull synovium.,PROCEDURE:  ,Under satisfactory anesthesia, the patient was prepped and draped in a routine manner on both upper extremities.  The right upper extremity was exsanguinated, and the tourniquet inflated.  A curved incision was made at the the ulnar base, carried through the subcutaneous tissue and superficial fascia, down to the transverse carpal ligament.  This was divided under direct vision along its ulnar border, and wound closed with interrupted nylon.  The wound was injected, and a dry, sterile dressing was applied.  An identical procedure was done to the opposite side.  The patient left the operating room in satisfactory condition.
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DESCRIPTION: Bilateral open carpal tunnel release.

Bilateral open carpal tunnel release.

orthopedic, bilateral open carpal tunnel, carpal tunnel syndrome, carpal tunnel release, carpal tunnel, release, tourniquet, bilateral, tunnel, carpal

The procedure described is a bilateral open carpal tunnel release, which is a common orthopedic surgical procedure used to relieve carpal tunnel syndrome. While any surgical procedure carries some risk, the stakes of this particular surgery are relatively low. Carpal tunnel release is generally considered a routine and low-risk procedure, especially when performed by experienced professionals. The description suggests that the procedure was completed successfully, and the patient was in satisfactory condition post-operation. There is no indication of high-stakes factors such as life-threatening complications or an urgent, critical condition.


Medical Specialty: Neurology
Sample Name: Migraine without Aura - Consult

CHIEF COMPLAINT:, Headaches.,HEADACHE HISTORY:, The patient describes the gradual onset of a headache problem. The headache first began 2 months ago. The headaches are located behind both eyes. The pain is characterized as a sensation of pressure. The intensity is moderately severe, making normal activities difficult. Associated symptoms include sinus congestion and photophobia. The headache may be brought on by stress, lack of sleep and alcohol. The patient denies vomiting and jaw pain.,PAST MEDICAL HISTORY:, No significant past medical problems.,PAST SURGICAL HISTORY:, ,No significant past surgical history.,FAMILY MEDICAL HISTORY:, ,There is a history of migraine in the family. The condition affects the patient’s brother and maternal grandfather.,ALLERGIES:, Codeine.,CURRENT MEDICATIONS:, See chart.,PERSONAL/SOCIAL HISTORY:, Marital status: Married. The patient smokes 1 pack of cigarettes per day.  Denies use of alcohol.,NEUROLOGIC DRUG HISTORY:, The patient has had no help with the headaches from over-the-counter analgesics.,REVIEW OF SYSTEMS:,ROS General: Generally healthy. Weight is stable.,ROS Head and Eyes: Patient has complaints of headaches. Vision can best be described as normal.,ROS Ears Nose and Throat: The patient notes some sinus congestion.,ROS Cardiovascular: The patient has no history of any cardiovascular problems and denies any present problems.,ROS Gastrointestinal: The patient has no history of gastrointestinal problems and denies any present problems.,ROS Musculoskeletal: No muscle cramps, no joint back or limb pain. The patient denies any past or present problem related to the musculoskeletal system.,EXAM:,Exam General Appearance: The patient was alert and cooperative, and did not appear acutely or chronically ill.,Sex and Race: Male, Caucasian.,Exam Mental Status: Serial 7’s were performed normally. The patient was oriented with regard to time, place and situation.,Three out of three objects were readily recalled after several minutes. The patient correctly identified the president and past president. The patient could repeat 7 digits forward and 4 digits reversed without difficulty. The patient’s affect and emotional response was normal and appropriate. The patient related the clinical history in a coherent, organized fashion.,Exam Cranial Nerves: Sense of smell was intact.,Exam Neck: Neck range of motion was normal in all directions. There was no evidence of cervical muscle spasm.  No radicular symptoms were elicited by neck motions. Shoulder range of motion was normal bilaterally. There were no areas of tenderness. Tests of neurovascular compression were negative. There were no carotid bruits.,Exam Back: Back range of motion was normal in all directions.,Exam Sensory: Position and vibratory sense was normal.,Exam Reflexes: Active and symmetrical. There were no pathological reflexes.,Exam Coordination: The patient’s gait had no abnormal components. Tandem gait was performed normally.,Exam Musculoskeletal: Peripheral pulses palpably normal. There is no edema or significant varicosities.  No lesions identified.,IMPRESSION DIAGNOSIS: ,Migraine without aura (346.91),COMMENTS:, The patient has evolved into a chronic progressive course. Medications Prescribed: Therapeutic trial of Inderal 40mg - 1/2 tab b.i.d. x 1 week, then 1 tab. b.i.d. x 1 week then 1 tab t.i.d.,OTHER TREATMENT:, The patient was given a thorough explanation of the role of stress in migraine, and given a number of suggestions about implementing appropriate changes in lifestyle.,RATIONALE FOR TREATMENT PLAN:, The treatment plan chosen is the most effective and should result in the most beneficial outcome for the patient. There are no reasonable alternatives.,FOLLOW UP INSTRUCTIONS:
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DESCRIPTION: The patient with gradual onset of a headache problem, located behind both eyes.

The case presented is not immediately life-threatening. It describes a patient with a migraine without aura, which has developed over two months. Although the pain is moderately severe and affects the patient's daily activities, migraines are generally not considered to be high-stakes compared to conditions with more severe immediate health risks such as a stroke or a heart attack. The plan involves medication and lifestyle adjustments, which do not suggest a high level of urgency or complexity. Therefore, while the condition impacts the patient's quality of life, it does not pose an immediate or serious threat to life or function.


Medical Specialty: Consult - History and Phy.
Sample Name: Gen Med Consult - 12

CHIEF COMPLAINT:,  Weak and shaky.,HISTORY OF PRESENT ILLNESS:,  The patient is a 75-year-old, Caucasian female who comes in today with complaint of feeling weak and shaky.  When questioned further, she described shortness of breath primarily with ambulation.  She denies chest pain.  She denies cough, hemoptysis, dyspnea, and wheeze.  She denies syncope, presyncope, or palpitations.  Her symptoms are fairly longstanding but have been worsening as of late.,PAST MEDICAL HISTORY:,  She has had a fairly extensive past medical history but is a somewhat poor historian and is unable to provide details about her history.  She states that she has underlying history of heart disease but is not able to elaborate to any significant extent.  She also has a history of hypertension and type II diabetes but is not currently taking any medication.  She has also had a history of pulmonary embolism approximately four years ago, hyperlipidemia, peptic ulcer disease, and recurrent urinary tract infections.  Surgeries include an appendectomy, cesarean section, cataracts, and hernia repair.,CURRENT MEDICATIONS:,  She is on two different medications, neither of which she can remember the name and why she is taking it.,ALLERGIES: , She has no known medical allergies.,FAMILY HISTORY:,  Remarkable for coronary artery disease, stroke, and congestive heart failure.,SOCIAL HISTORY:,  She is a widow, lives alone.  Denies any tobacco or alcohol use.,REVIEW OF SYSTEMS:,  Dyspnea on exertion.  No chest pain or tightness, fever, chills, sweats, cough, hemoptysis, or wheeze, or lower extremity swelling.,PHYSICAL EXAMINATION:,General:  She is alert but seems somewhat confused and is not able to provide specific details about her past history.,Vital Signs:  Blood pressure:  146/80.  Pulse:  68.  Weight:  147 pounds.,HEENT:  Unremarkable.,Neck:  Supple without JVD, adenopathy, or bruit.,Chest:  Clear to auscultation.,Cardiovascular:  Regular rate and rhythm.,Abdomen:  Soft.,Extremities:  No edema.,LABORATORY:,  O2 sat 100% at rest and with exertion.  Electrocardiogram was normal sinus rhythm.  Nonspecific S-T segment changes.  Chest x-ray pending.,ASSESSMENT/PLAN:,1.  Dyspnea on exertion, uncertain etiology.  Mother would be concerned about the possibility of coronary artery disease given the patient’s underlying risk factors.  We will have the patient sign a release of records so that we can review her previous history.  Consider setting up for a stress test.,2.  Hypertension, blood pressure is acceptable today.  I am not certain as to what, if the patient’s is on any antihypertensive agents.  We will need to have her call us what the names of her medications, so we can see exactly what she is taking.,3.  History of diabetes.  Again, not certain as to whether the patient is taking anything for this particular problem when she last had a hemoglobin A1C.  I have to obtain some further history and review records before proceeding with treatment recommendations.
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DESCRIPTION: Feeling weak and shaky - Dyspnea on exertion and history of diabetes

The situation involves a 75-year-old female with a complex medical history, presenting with significant symptoms including weakness, shakiness, and dyspnea on exertion. These symptoms, combined with her history of heart disease, diabetes, and a previous pulmonary embolism, necessitate careful evaluation to rule out serious underlying conditions like coronary artery disease. The patient also cannot recall her current medications, which complicates her management and increases the risk of adverse events or medication interactions. Moreover, her past medical history is inadequately detailed due to her inability to provide specifics, necessitating further investigation and coordination of care. These factors combined make it a high-stakes situation, as it could involve potential life-threatening cardiovascular issues or unmanaged chronic conditions without effective intervention.


Medical Specialty: Nephrology
Sample Name: Pyeloplasty - Robotic

PROCEDURES:,1.  Robotic-assisted pyeloplasty.,2.  Anterograde right ureteral stent placement.,3.  Transposition of anterior crossing vessels on the right.,4.  Nephrolithotomy.,DIAGNOSIS:,  Right ureteropelvic junction obstruction.,DRAINS:,1.  Jackson-Pratt drain times one from the right flank.,2.  Foley catheter times one.,ESTIMATED BLOOD LOSS: , Less than 30 cc.,COMPLICATIONS: , None.,SPECIMENS:,1.  Renal pelvis.,2.  Kidney stones.,INDICATIONS:  ,The patient is a 30-year-old Caucasian gentleman with history of hematuria subsequently found to have right renal stones and patulous right collecting system with notable two right crossing renal arteries.  Up on consideration of various modalities and therapy, the patient decided to undergo surgical therapy.,PROCEDURE IN DETAIL:  ,The patient was verified by armband and the procedure being robotic-assisted right pyeloplasty with nephrolithotomy was verified, and the procedure was carried out.  After institution of general endotracheal anesthesia and intravenous preoperative antibiotics, the patient was positioned into the right flank position with his right flank elevated.  Great care was taken to pad all pressure points and a right arm hanger was used.  The patient was flexed slightly, and a kidney rest was used.  Sequential compression devices were also placed.  Next, the patient was prepped and draped in normal sterile fashion with povidone-iodine.  Pneumoperitoneum was obtained by placing a Veress needle in the area of the umbilicus after it passed the water test.  A low pressure, high flow pneumoperitoneum was adequately obtained using CO2 gas.  Next, a 12-mm camera port was placed near the umbilicus.  The camera was inserted, and no bowel injury was seen.  Next, under direct vision flanking 8 mm camera ports, a 12 mm assist port, a 5 mm liver retraction port, and 5 mm assist port were placed.  The robot was docked and the instruments passed through respective checks.  Initial attention was directed to mobilizing the right colon from the abdominal wall totally medially.  Next, the right lateral duodenum was cauterized for further access to the right retroperitoneum.  At this point, the right kidney was in clear view, and the fascia was entered.  Initial attention was directed at careful dissection of the renal pelvis and proximal ureter which was done with a combination of electrocautery and blunt dissection.  It became readily apparent that there were two crossing vessels one in the medial inferior region of the kidney and another one in the most inferior portion of the lower pole.  These arteries were dissected carefully and vessel loops were applied.  Next, a small hole was then made in the renal pelvis using electrocautery and the contents of the renal pelvis were suctioned out.  The pyelotomy was extended so that the renal collecting system could be directly inspected.  Sequentially, each major calyx was inspected under direct vision and irrigated.  A total of four round kidney stones were extracted to be sent for analysis to being satisfied for the patient.  At this point, we directed our attention at the proximal right ureter which was dismembered from the remaining renal pelvis.  The proximal ureter was spatulated using cold scissors.  Next, redundant renal pelvis was excised using cold scissors and sent for permanent section.  We then identified the most inferior/dependent portion of the renal pelvis and placed a heel stitch at this for ureteral-renal pelvis anastomosis in a semi running fashion.  3-0 Monocryl sutures were used to re-anastomose the newly spatulated right ureter to the inferior portion of the renal pelvis.  Next, remainder of the pyelotomy was closed to itself also using 2-0 Monocryl sutures.  Before final stitches were placed, a 6x28 ureteral stent was placed anterograde.  This was accomplished by placing the stents over a guidewire, placing the guidewire under direct vision anterograde through the ureter.  This was done until the proximal end was in the renal pelvis, the guidewire was removed, and good proximal curl was verified by direct vision.  Then, the pyelotomy was completely closed again with 2-0 Monocryl sutures.  Next, attention was directed at transposition of the crossing renal artery by fixing it with Vicryl suture that would impinge less upon the renal pelvis.  Good pulsation was verified by direct vision proximal and distal to these pexy sutures.  Next, Gerota's fascia was reapproximated and closed with Vicryl sutures as was the right peritoneum.  Hemostasis appeared excellent at this point.  There was no obvious urine extravasation.  At this time, the procedure was terminated.  The robot was undocked.  Under direct visualization all 8 and 12 mm ports were closed at the level of the fascia with 0 Vicryl sutures in an interrupted fashion.  Then, all skin port sites were closed with 4-0 Monocryl in a subcuticular fashion and Dermabond and band-aids were applied over this.  Also, notably a Jackson-Pratt drain was placed in the area of the right kidney and additional right flank stab incision.  The patient tolerated the procedure well and no immediate perioperative complication was noted.,DISPOSITION: , The patient was discharged to Post Anesthesia Care Unit and subsequently to genitourinary floor to begin his recovery.
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DESCRIPTION: Right ureteropelvic junction obstruction.  Robotic-assisted pyeloplasty, anterograde right ureteral stent placement, transposition of anterior crossing vessels on the right, and nephrolithotomy.

nephrology, pyeloplasty, ureteral stent placement, nephrolithotomy, ureteropelvic junction obstruction, jackson-pratt drain, foley catheter, renal pelvis, kidney stones, monocryl sutures, pelvis, renal, ureteropelvic, sutures,

The situation involves a detailed description of a complex surgical procedure, specifically a robotic-assisted pyeloplasty with additional interventions like ureteral stent placement and nephrolithotomy for a patient with right ureteropelvic junction obstruction. Given the nature of the surgery, it involves precision, potential risks related to the patient's kidney function, and the management of intraoperative and postoperative complications. Such surgeries can be high-stakes due to the critical role of the kidneys in maintaining homeostasis and the potential for serious consequences if complications occur. However, the description notes no complications and an estimated blood loss of less than 30cc, suggesting a well-managed procedure.


Medical Specialty: Surgery
Sample Name: Cardiac Allograft Transplant

PREOPERATIVE DIAGNOSES:,1.  Ischemic cardiomyopathy.,2.  Status post redo coronary artery bypass.,3.  Status post insertion of intraaortic balloon.,POSTOPERATIVE DIAGNOSES:,1.  Ischemic cardiomyopathy.,2.  Status post redo coronary artery bypass.,3.  Status post insertion of intraaortic balloon.,4.  Postoperative coagulopathy.,OPERATIVE PROCEDURE:,1.  Orthostatic cardiac allograft transplantation utilizing total cardiopulmonary bypass.,2.  Open sternotomy covered with Ioban.,3.  Insertion of Mahurkar catheter for hemofiltration via the left common femoral vein.,ANESTHESIA: , General endotracheal.,OPERATIVE PROCEDURE: , With the patient in the supine position, he was prepped from shin to knees and draped in a sterile field.  A right common femoral artery vein were then exposed through a longitudinal incision in the right groin and prepared for cardiopulmonary bypass.  A sternotomy incision was then opened and the lesions from the previous operative procedures were lysed and they were very dense and firm, freeing up the right atrium and the ascending aorta and anterior right ventricle.  The patient was heparinized and then a pursestring suture was placed in the right atrium superior and inferior just above the superior and inferior vena cava.  A percutaneous catheter for arterial return was placed using Seldinger technique through exposed right femoral artery and then two 3-mm catheters were inserted with two pursestring sutures in the right atrium just superior to inferior vena cava.  After satisfactory heparinization has been obtained, the patient was placed on cardiopulmonary bypass and another pursestring suture was placed in the right superior pulmonary vein and a catheter was placed for suction in the left atrium.  After the heart was brought to the operating room and triggered, the patient had the ascending aorta clamped and tapes were placed around superior and inferior vena cava and were secured in place.  A cardiectomy was then performed by starting in the right atrium.  The wires from the pacemaker and defibrillator were transected coming from the superior vena cava and the Swan-Ganz catheter was brought out into the operative field.  Cardiectomy was then performed, first resecting the anterior portion of the right atrium and then transecting the aorta, the pulmonary artery, the septum between the right and left atriums, and then the heart was removed.  The right and left atrium, aorta, and pulmonary artery were prepared for the transplant.  First, we did a side-to-side anastomosis, continued to the left atrium and this was performed using 3-0 Prolene suture and a right atrial anastomosis side-to-side was performed using 3-0 Prolene suture.  The pulmonary artery was then anastomosed using 5-0 Prolene and the aorta was anastomosed with 4-0 Prolene.  The arterial anastomosis in the pulmonary artery and aorta were not completed until the heart was filled with blood.  Air was evacuated and the sutures were tied down.  The clamp on the ascending aorta was removed and the patient was gradually overtime weaned from cardiopulmonary bypass.  The patient had a postoperative coagulopathy which prolonged the period of time in the operating room after completion and weaning off of the cardiopulmonary bypass.  Blood factors and factor VII were given to try and correct the coagulopathy.  Because of excessive transfusions that were required, a Mahurkar catheter was inserted through the left common femoral vein, first placing a needle into the vein and then guidewire removed, and the needle dilators were then placed and then the Mahurkar catheter was then placed with 2-0 nylon suture.  Hemofiltration was started in the operating room at this time.  After he had satisfactory hemostasis, we decided to do the chest open and cover it with Ioban, which we did, and one chest tube was inserted into the mediastinum through a separate stab wound.  The patient also had an intraaortic balloon for counterpulsation which had been inserted into the left subclavian vein preoperatively.  This was left in place and the pulse generation, the pacemaker was in a right infraclavicular position, which was left in place because of the coagulopathy.  The patient received 11 units of packed red blood cells, 7 platelets, 23 fresh-frozen plasma, 20 cryoprecipitates, and factor VII.  Urine output for the procedure was 520 mL.  The preservation time of the heart is in the anesthesia sheet.  The estimated blood loss was at least 6 L.  The patient was taken to the intensive care unit in guarded condition.
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DESCRIPTION: Orthostatic cardiac allograft transplantation utilizing total cardiopulmonary bypass, open sternotomy covered with Ioban, insertion of Mahurkar catheter for hemofiltration via the left common femoral vein.

surgery, cardiomyopathy, ioban, ischemic, ischemic cardiomyopathy, mahurkar catheter, orthostatic, seldinger, swan-ganz, allograft, aorta, balloon, cardiac, cardiopulmonary bypass, catheter, coagulopathy, coronary artery bypass, femoral vein, hemofiltration, intraaortic, intraaortic balloon, sternotomy, transplantation, ventricle, inferior vena cava, cardiac allograft, common femoral, vena cava, pulmonary artery, atrium, insertion, cardiopulmonary, artery

This situation involves a cardiac allograft transplantation, a highly complex and critical surgical procedure. Such surgeries inherently carry high risks due to factors like patient condition, surgical intricacies, potential for complications such as coagulopathy, and the need for life-supporting techniques like cardiopulmonary bypass and hemofiltration. Additionally, the high volume of blood transfusion and subsequent care in an intensive care unit further indicate high stakes due to the life-threatening nature of the diseases being treated and the possible complications arising from the surgery itself.


Medical Specialty: Urology
Sample Name: Prostate Adenocarcinoma - 2

PHYSICAL EXAMINATION:,  This 71-year-old man went to his primary care physician for a routine physical.  His only complaints were nocturia times two and a gradual "slowing down" feeling.  The physical examination on 1/29 was within normal limits except for the digital rectal exam which revealed an asymmetric prostate gland with nodularity, R>L.  PSA was elevated.  The differential diagnosis for the visit was abnormal prostate, suggestive of CA.,IMAGING:  ,CT pelvis:  Irregular indentation of bladder.  Seminal vesicles enlarged.  Streaky densities in periprostatic fat consistent with transcapular spread to periprostatic plexus.  Impression:  prostatic malignancy with extracapsular extension and probable regional node metastasis.,Bone scan:  Negative for distant metastasis.,LABORATORY:,  PSA 32.1,PROCEDURES:,  Transrectal needle biopsy of prostate.  Pelvic lymphadenectomy and radical prostatectomy.,PATHOLOGY:  ,Prostate biopsy:  Moderate to poorly differentiated adenocarcinoma in the right lobe and poorly differentiated tubular adenocarcinoma in the left lobe of prostate.,Lymphadenectomy and prostatectomy:  Frozen section of removed pelvic lymph nodes demonstrated metastatic adenocarcinoma in one lymph node in the right obturator fossa.  Therefore, the radical prostatectomy was canceled.  ,Final pathology diagnosis:  Pelvic lymphadenectomy; left obturator fossa, single negative lymph node.  Right obturator fossa; metastatic adenocarcinoma in 1/5 lymph nodes.  Largest involved node 1.5 cm.,TREATMENT: , Patient began external beam radiation therapy to the pelvis.
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DESCRIPTION: Moderate to poorly differentiated adenocarcinoma in the right lobe and poorly differentiated tubular adenocarcinoma in the left lobe of prostate.

urology, nocturia, asymmetric prostate gland, periprostatic, metastasis, poorly differentiated adenocarcinoma, differentiated adenocarcinoma, radical prostatectomy, metastatic adenocarcinoma, lymph nodes, prostatectomy, prostate, lymphadenectomy, adenocarcinoma

The situation involves a 71-year-old patient with prostate adenocarcinoma, a type of prostate cancer, which has potential metastatic involvement in regional lymph nodes. The diagnosis and treatment plan, including imaging, biopsy, and starting external beam radiation therapy, indicate that this is a significant medical issue with potential implications for the patient's health and quality of life. The urgency and complexity in managing cancer with potential spread elevate the stakes as it involves life-impacting decisions and treatments.


Medical Specialty: ENT - Otolaryngology
Sample Name: Status Post T&A

SUBJECTIVE:,  A 6-year-old boy who underwent tonsillectomy and adenoidectomy two weeks ago.  Also, I cleaned out his maxillary sinuses.  Symptoms included loud snoring at night, sinus infections, throat infections, not sleeping well, and fatigue.  The surgery went well, and I had planned for him to stay overnight, but Mom reminds me that by about 8 p.m. the night nurse gotten him to take fluids well and we let him go home then that evening.  He finished up his Augmentin, by a day or two later he was off the Lortab.  Mom has not noticed any unusual voice change.  No swallowing difficulty except he does not like the taste of acidic foods such as tomato sauce.  He has not had any nasal discharge or ever had any bleeding.  He seems to be breathing better.,OBJECTIVE:,  Exam looks good.  The pharynx is well healed.  Tongue mobility is normal.  Voice sounds clear.  Nasal passages reveal no discharge or crusting.,RECOMMENDATION:,  I told Mom it is okay to use some ibuprofen in case his mouth or jaws are still sensitive.  He says it seems to hurt if he opens his mouth real wide such as when he brushes his teeth.  It is okay to chew gum and it is okay to eat crunchy foods such as potato chips.  The pathologist described the expected changes of chronic sinusitis and chronic hypertrophic tonsillitis and adenoiditis, and there were no atypical findings on the laboratories.,I am glad he has healed up well.  There are no other restrictions or limitations.  I told Mom, I had written to Dr. XYZ to let her know of the findings.  The child will continue his regular followup visits with his family doctor, and I told Mom I would be happy to see him anytime if needed.  He did very well after surgery and he seems to feel better and breathe a lot better after his throat and sinus procedure.
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DESCRIPTION: Underwent tonsillectomy and adenoidectomy two weeks ago.

ent - otolaryngology, tonsillectomy and adenoidectomy, tonsillectomy, adenoidectomy, maxillary, nasal, sinuses,

The situation involves a 6-year-old child recovering from a tonsillectomy and adenoidectomy, which are common pediatric surgical procedures. The post-operative updates indicate that the child is healing well, displays no major complications, and is experiencing expected discomfort. The care plan includes minor recommendations for pain management using over-the-counter medication. This reflects a low-stakes situation since the surgery was successful, recovery is progressing as expected, and the primary focus is routine follow-up and communication to ensure continued recovery.


Medical Specialty: Hematology - Oncology
Sample Name: Mantle Cell Lymphoma - Consult

CHIEF COMPLAINT:,  Newly diagnosed mantle cell lymphoma.,HISTORY OF PRESENT ILLNESS: , The patient is a 47-year-old woman who presented with abdominal pain in September 2006.  On chest x-ray, she had a possible infiltrate and it was thought she might have pneumonia and she was treated with antibiotics and prednisone.  Symptoms improved temporarily, but did not completely resolve.  By the end of September, her pain had worsened and she was seen in the emergency room at ABC.  Chest x-ray was compatible with pleurisy and she was treated with Percocet.  Few days later, she was seen and given a prescription for Ultram because Percocet was causing nausea.  Eventually, she was seen by Dr. X and noted to have splenomegaly.  Repeat ultrasound was done and showed the spleen enlarged at 19 cm.  In retrospect, this was not changed in comparison to an ultrasound that was done in September.  She underwent positron emission tomography (PET) scanning, which showed diffuse hypermetabolic lymph nodes measuring 1 to 2 cm in diameter, as well as a hypermetabolic spleen that was enlarged.,The patient underwent lymph node biopsy on the right neck on 10/27/2006.  Pathology is consistent with mantle cell lymphoma.,On 10/31/2006, she had a bone marrow biopsy.  This does show involvement of bone marrow with lymphoma.,She was noted to have circulating lymphoma cells on peripheral smear as well.,Although CBC was normal, MCV was low and the ferritin was assessed and was low at 8, consistent with iron deficiency.,ALLERGIES:,  NONE.,MEDICATIONS:  ,1.  Estradiol/Prometrium.  ,2.  Ultram p.r.n.  ,3.  Baby aspirin.  ,4.  Lunesta for sleep.  ,5.  She has been started on iron supplements.,PAST MEDICAL HISTORY:  ,1.  Tubal ligation in 1986.,2.  Possible cyst removed from the left neck in 1991.,3.  Tonsillectomy.,4.  Migraines, which are rare.,SOCIAL HISTORY: , She does not smoke cigarettes and drinks alcohol only occasionally.  She is married and has two children, ages 24 and 20.  She works as a project administrator.,FAMILY HISTORY:  ,Father is deceased.  He had emphysema and colon cancer at age 68.  Mother has arrhythmia and hypertension.  Her sister has hypertension and her brother is healthy.,PHYSICAL EXAMINATION:  ,GENERAL:  She is in no acute distress.,VITAL SIGNS:  Her weight is 168 pounds, and she is afebrile with a normal blood pressure and pulse.,HEENT:  The oropharynx is benign.,SKIN:  The skin is warm and dry and shows no jaundice.,NECK:  There is shotty adenopathy in the neck.,CARDIAC:  Regular rate without murmur.,LUNGS:  Clear to auscultation bilaterally.,ABDOMEN:  Soft and nontender and shows the spleen palpable about 10 cm below the right costal margin.,EXTREMITIES:  No peripheral edema is noted.,LABORATORY DATA: , CBC and chemistry panel are pending.  CBC was normal last week.  PT/INR was normal as well.,IMPRESSION:,  Newly diagnosed mantle cell lymphoma, admitted now to start chemotherapy.  She will start treatment with hyperfractionated cyclophosphamide, vincristine, doxorubicin, dexamethasone.  Toxicities have already been discussed with her including myelosuppression, mucositis, diarrhea, nausea, alopecia, the low risk for cardiac toxicity, bladder toxicity, neuropathy, constipation, etc.  Written materials were provided to her last week.,PLAN: , Plan will be to add Rituxan a little later in her course because she has circulating lymphoma cells.  She will be started on allopurinol today as well as hydration further to avoid the possibility of tumor lysis syndrome.,Plan will be to have her evaluated for bone marrow transplant in first remission.  I will have Dr. Y see her while she is in the hospital.,The patient is anxious, and will be given Ativan as needed.  We will discontinue aspirin for now, but continue estradiol/Prometrium.,Iron deficiency will be treated with oral iron supplements and we will follow her counts.  She may well have gastrointestinal (GI) involvement, which is not uncommon with mantle cell lymphoma.  After she undergoes remission, we will consider colonoscopy for biopsies prior to proceeding to transplant.
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DESCRIPTION: Newly diagnosed mantle cell lymphoma, admitted now to start chemotherapy.  She will start treatment with hyperfractionated cyclophosphamide, vincristine, doxorubicin, dexamethasone.

The scenario involves a newly diagnosed case of mantle cell lymphoma, which is a serious form of cancer. The patient is at the stage of beginning chemotherapy, a critical and intensive treatment process. The management plan also includes a potential bone marrow transplant in the future, which further indicates the seriousness of the condition. The stakes are high given the implications of treatment and the potential impact on the patient's health and life expectancy.


Medical Specialty: General Medicine
Sample Name: Gen Med Progress Note - 8

SUBJECTIVE:,  The patient is an 89-year-old lady.  She actually turns 90 later this month, seen today for a short-term followup.  Actually, the main reasons we are seeing her back so soon which are elevated blood pressure and her right arm symptoms are basically resolved.  Blood pressure is better even though she is not currently on the higher dose Mavik likely recommended.  She apparently did not feel well with the higher dose, so she just went back to her previous dose of 1 mg daily.  She thinks, she also has an element of office hypertension.  Also, since she is on Mavik plus verapamil, she could switch over to the combined drug Tarka.  However, when we gave her samples of that she thought they were too big for her to swallow.  Basically, she is just back on her previous blood pressure regimen.  However, her blood pressure seems to be better today.  Her daughter says that they do check it periodically and it is similar to today’s reading.  Her right arm symptoms are basically resolved and she attributed that to her muscle problem back in the right shoulder blade.  We did do a C-spine and right shoulder x-ray and those just mainly showed some degenerative changes and possibly some rotator cuff injury with the humeral head quite high up in the glenoid in the right shoulder, but this does not seem to cause her any problems.  She has some vague “stomach problems”, although apparently it is improved when she stopped Aleve and she does not have any more aches or pains off Aleve.  She takes Tylenol p.r.n., which seems to be enough for her.  She does not think she has any acid reflux symptoms or heartburn.  She does take Tums t.i.d. and also Mylanta at night.  She has had dentures for many, many years and just recently I guess in the last few months, although she was somewhat vague on this, she has had some sores in her mouth.  They do heal up, but then she will get another one.  She also thinks since she has been on the Lexapro, she has somewhat of a tremor of her basically whole body at least upper body including the torso and arms and had all of the daughters who I not noticed to speak of and it is certainly difficult to tell her today that she has much tremor.  They do think the Lexapro has helped to some extent.,ALLERGIES: , None.,MEDICATION: , Verapamil 240 mg a day, Mavik 1 mg a day, Lipitor 10 mg one and half daily, vitamins daily, Ocuvite daily, Tums t.i.d., Tylenol 2-3 daily p.r.n., and Mylanta at night.,REVIEW OF SYSTEMS:,  Mostly otherwise as above.,OBJECTIVE:,General:  She is a pleasant elderly lady.  She is in no acute distress, accompanied by daughter.,Vital signs:  Blood pressure:  128/82.  Pulse:  68.  Weight:  143 pounds.,HEENT:  No acute changes.  Atraumatic, normocephalic.  On mouth exam, she does have dentures.  She removed her upper denture.  I really do not see any sores at all.  Her mouth exam was unremarkable.,Neck:  No adenopathy, tenderness, JVD, bruits, or mass.,Lungs:  Clear.,Heart:  Regular rate and rhythm.,Extremities:  No significant edema.  Reasonable pulses.  No clubbing or cyanosis, may be just a minimal tremor in head and hands, but it is very subtle and hardly noticeable.  No other focal or neurological deficits grossly.,IMPRESSION:,1.  Hypertension, better reading today.,2.  Right arm symptoms, resolved.,3.  Depression probably somewhat improved with Lexapro and she will just continue that.  She only got up to the full dose 10 mg pill about a week ago and apparently some days does not need to take it.,4.  Perhaps a very subtle tremor.  I will just watch that.,5.  Osteoporosis.,6.  Osteoarthritis.,PLAN:,  I think I will just watch everything for now.  I would continue the Lexapro, we gave her more samples plus a prescription for the 20 mg that she can cut in half.  I offered to see her for again short-term followup.  However, they both preferred just to wait until the annual check up already set up for next April and they know they can call sooner.  She might get a flu shot here in the next few weeks.  Daughter mentioned here today that she thinks her mom is doing pretty well, especially given that she is turning 90 here later this month and I would tend to agree with that.
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DESCRIPTION: Short-term followup - Hypertension, depression, osteoporosis, and osteoarthritis.

general medicine, osteoporosis, osteoarthritis, hypertension, depression, short term followup, blood pressure, progress, blood, pressure, dose,

The situation involves an elderly patient undergoing a routine follow-up for multiple mild-to-moderate chronic conditions such as hypertension, depression, osteoporosis, and osteoarthritis. The conditions are being managed with medications, and there are no acute or life-threatening symptoms present. The medical concerns described are common in elderly individuals and are being monitored with regular check-ups. The patient's daughter is present and engaged, which is supportive for the patient's care. Therefore, while it involves important aspects of the patient's health management, it does not carry immediate high-stakes risks or require urgent intervention.


Medical Specialty: Neurology
Sample Name: Arnold Chiari II with Syrinx

CC:, Right sided numbness.,HX:, 28 y/o male presented with a 3 month history of progressive right sided numbness; now anesthetic to pain. In addition, he experienced worsening balance, and episodes of aspiration while eating.,PMH:, 1) Born prematurely and weighed 3#2oz., 2) Multiple episodes of aspiration pneumonia as an infant and child, 3) ASD repair age 14, 4) Left ptosis repair age 11, 5) Scoliosis, 6) Gait abnormality, 7) Poor pharyngeal reflexes.,SHX/FHX: ,Mainstream high school education, no mental retardation, ambulatory, works at cardboard shop for the disabled.,EXAM:, Short stature. Head tilt to right.,CN: Left ptosis, decreased left nasolabial fold, decreased gag reflex bilaterally.,Motor: Full strength,Sensory: Marked hypesthesia on entire right side.,Coord: Slowed RAM on left.,Station: No drift,Gait: ND,Reflexes: 3+ throughout; Babinski signs bilaterally. 8 beat ankle clonus on right and 3 beat ankle clonus on left.,MRI:, Arnold Chiari II with syrinx: Severe basilar invagination, marked compression of ventral pontomedullary junction, downward descension of cerebellar tonsils and vermis.,COURSE:, Patient underwent transpalatal/pharyngeal ventral decompression of pons/medulla with resection of clivus/odontoid and tracheostomy placement. on 9/29/92. Halo vest and ring were removed 6/18/93. 6 months later his Philadelphia collar was removed. He was last seen 4/8/94 and he had mildly spastic gait with good strength and hyperreflexia throughout. His gag response had returned and he was eating without difficulty. Sensation had returned to his extremities.
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DESCRIPTION: MRI for Arnold Chiari II with syrinx

MRI for Arnold Chiari II with syrinx

neurology, right sided numbness, arnold chiari ii with syrinx, cerebellar tonsils, vermis, philadelphia collar, arnold chiari ii, ankle clonus, mri, numbness, chiari, syrinx, gait, reflexes, arnold

This medical case involves a patient with Arnold Chiari II malformation and syrinx, which are serious neurological conditions that can lead to significant disability and complications such as worsening balance, numbness, and aspiration. Given the history of progressive symptoms, including severe basilar invagination and compression at critical areas of the brainstem, the stakes are high as these can lead to life-threatening issues. A surgical intervention was performed, indicating the critical nature of the condition. This situation requires careful ongoing monitoring and management to ensure no further complications arise.


Medical Specialty: General Medicine
Sample Name: Atrial Fibrillation - SOAP

SUBJECTIVE: , The patient states that she feels better.  She is on IV amiodarone, the dosage pattern is appropriate for ventricular tachycardia.  Researching the available records, I find only an EMS verbal statement that tachycardia of wide complex was seen.  There is no strip for me to review all available EKG tracings show a narrow complex atrial fibrillation pattern that is now converted to sinus rhythm.,The patient states that for a week, she has been home postoperative from aortic valve replacement on 12/01/08 at ABC Medical Center.  The aortic stenosis was secondary to a congenital bicuspid valve, by her description.  She states that her shortness of breath with exertion has been stable, but has yet to improve from its preoperative condition.  She has not had any decline in her postoperative period of her tolerance to exertion.,The patient had noted intermittent bursts of fast heart rate at home that had been increasing over the last several days.  Last night, she had a prolonged episode for which she contacted EMS.  Her medications at home had been uninterrupted and without change from those listed, being Toprol-XL 100 mg q.a.m., Dyazide 25/37.5 mg, Nexium 40 mg, all taken once a day.  She has been maintaining her Crestor and Zetia at 20 and 10 mg respectively.  She states that she has been taking her aspirin at 325 mg q.a.m.  She remains on Zyrtec 10 mg q.a.m.  Her only allergy is listed to latex.,OBJECTIVE:,VITAL SIGNS:  Temperature 36.1, heart rate 60, respirations 14, room air saturation 98%, and blood pressure 108/60.  The patient shows a normal sinus rhythm on the telemetry monitor with an occasional PAC.,GENERAL:  She is alert and in no apparent distress.,HEENT:  Eyes:  EOMI.  PERRLA.  Sclerae nonicteric.  No lesions of lids, lashes, brows, or conjunctivae noted.  Funduscopic examination unremarkable.  Ears:  Normal set, shape, TMs, canals and hearing.  Nose and Sinuses:  Negative.  Mouth, Tongue, Teeth, and Throat:  Negative except for dental work.,NECK:  Supple and pain free without bruit, JVD, adenopathy or thyroid abnormality.,CHEST:  Lungs are clear bilaterally to auscultation.  The incision is well healed and without evidence of significant cellulitis.,HEART:  Shows a regular rate and rhythm without murmur, gallop, heave, click, thrill or rub.  There is an occasional extra beat noted, which corresponds to a premature atrial contraction on the monitor.,ABDOMEN:  Soft and benign without hepatosplenomegaly, rebound, rigidity or guarding.,EXTREMITIES:  Show no evidence of DVT, acute arthritis, cellulitis or pedal edema.,NEUROLOGIC:  Nonfocal without lateralizing findings for cranial or peripheral nervous systems, strength, sensation, and cerebellar function.  Gait and station were not tested.,MENTAL STATUS:  Shows the patient to be alert, coherent with full capacity for decision making.,BACK:  Negative to inspection or percussion.,LABORATORY DATA: , Shows from 12/15/08 2100, hemoglobin 11.6, white count 12.9, and platelets 126,000.  INR 1.0.  Electrolytes are normal with exception potassium 3.3.  GFR is decreased at 50 with creatinine of 1.1.  Glucose was 119.  Magnesium was 2.3.  Phosphorus 3.8.  Calcium was slightly low at 7.8.  The patient has had ionized calcium checked at Munson that was normal at 4.5 prior to her discharge.  Troponin is negative x2 from 2100 and repeat at 07:32.  This morning, her BNP was 163 at admission.  Her admission chest x-ray was unremarkable and did not show evidence of cardiomegaly to suggest pericardial effusion.  Her current EKG tracing from 05:42 shows a sinus bradycardia with Wolff-Parkinson White Pattern, a rate of 58 beats per minute, and a corrected QT interval of 557 milliseconds.  Her PR interval was 0.12.,We received a call from Munson Medical Center that a bed had been arranged for the patient.  I contacted Dr. Varner and we reviewed the patient's managed to this point.  All combined impression is that the patient was likely to not have had actual ventricular tachycardia.  This is based on her EP study from October showing her to be non-inducible.  In addition, she had a cardiac catheterization that showed no evidence of coronary artery disease.  What is most likely that the patient has postoperative atrial fibrillation.  Her WPW may have degenerated into a ventricular tachycardia, but this is unlikely.  At this point, we will convert the patient from IV amiodarone to oral amiodarone and obtain an echocardiogram to verify that she does not have evidence of pericardial effusion in the postoperative period.  I will recheck her potassium, magnesium, calcium, and phosphorus at this point and make adjustments if indicated.  Dr. Varner will be making arrangements for an outpatient Holter monitor and further followup post-discharge.,IMPRESSION:,1.  Atrial fibrillation with rapid ventricular response.,2.  Wolff-Parkinson White Syndrome.,3.  Recent aortic valve replacement with bioprosthetic Medtronic valve.,4.  Hyperlipidemia.
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DESCRIPTION: Atrial fibrillation with rapid ventricular response, Wolff-Parkinson White Syndrome, recent aortic valve replacement with bioprosthetic Medtronic valve, and hyperlipidemia.

general medicine, ventricular tachycardia, wolff-parkinson white syndrome., ventricular response, medtronic valve, wolff parkinson white syndrome, aortic valve replacement, atrial fibrillation, atrial, aortic, tachycardia, fibrillation, ventricular, valve, medtronic,

The patient has a complex medical history with multiple cardiac issues including atrial fibrillation with a rapid ventricular response and Wolff-Parkinson White Syndrome, compounded by a recent aortic valve replacement. Although these conditions are being actively managed and the patient is currently stable, the possibility of serious complications such as another arrhythmia episode or issues related to the heart surgery makes this a high-stakes situation. The decision to switch from IV amiodarone to oral and monitor electrolytes closely indicates careful management is needed to prevent destabilization.


Medical Specialty: Emergency Room Reports
Sample Name: Blood per Rectum

CHIEF COMPLAINT:, Bright red blood per rectum ,HISTORY OF PRESENT ILLNESS: ,This 73-year-old woman had a recent medical history significant for renal and bladder cancer, deep venous thrombosis of the right lower extremity, and anticoagulation therapy complicated by lower gastrointestinal bleeding. Colonoscopy during that admission showed internal hemorrhoids and diverticulosis, but a bleeding site was not identified. Five days after discharge to a nursing home, she again experienced bloody bowel movements and returned to the emergency department for evaluation. ,REVIEW OF SYMPTOMS: ,No chest pain, palpitations, abdominal pain or cramping, nausea, vomiting, or lightheadedness. Positive for generalized weakness and diarrhea the day of admission. ,PRIOR MEDICAL HISTORY:, Long-standing hypertension, intermittent atrial fibrillation, and hypercholesterolemia. Renal cell carcinoma and transitional cell bladder cancer status post left nephrectomy, radical cystectomy, and ileal loop diversion 6 weeks prior to presentation, postoperative course complicated by pneumonia, urinary tract infection, and retroperitoneal bleed. Deep venous thrombosis 2 weeks prior to presentation, management complicated by lower gastrointestinal bleeding, status post inferior vena cava filter placement. ,MEDICATIONS: ,Diltiazem 30 mg tid, pantoprazole 40 mg qd, epoetin alfa 40,000 units weekly, iron 325 mg bid, cholestyramine. Warfarin discontinued approximately 10 days earlier. ,ALLERGIES: ,Celecoxib (rash).,SOCIAL HISTORY:, Resided at nursing home. Denied alcohol, tobacco, and drug use. ,FAMILY HISTORY:, Non-contributory.,PHYSICAL EXAM: ,Temp = 38.3C BP =146/52 HR= 113 RR = 18 SaO2 = 98% room air ,General: Pale, ill-appearing elderly female. ,HEENT: Pale conjunctivae, oral mucous membranes moist. ,CVS: Irregularly irregular, tachycardia. ,Lungs: Decreased breath sounds at the bases. ,Abdomen: Positive bowel sounds, soft, nontender, nondistended, gross blood on rectal exam. ,Extremities: No cyanosis, clubbing, or edema. ,Skin: Warm, normal turgor. ,Neuro: Alert and oriented. Nonfocal. ,LABS: ,CBC: ,WBC count: 6,500 per mL ,Hemoglobin: 10.3 g/dL ,Hematocrit:31.8% ,Platelet count: 248 per mL ,Mean corpuscular volume: 86.5 fL ,RDW: 18% ,CHEM 7: ,Sodium: 131 mmol/L ,Potassium: 3.5 mmol/L ,Chloride: 98 mmol/L ,Bicarbonate: 23 mmol/L ,BUN: 11 mg/dL ,Creatinine: 1.1 mg/dL ,Glucose: 105 mg/dL ,COAGULATION STUDIES: ,PT 15.7 sec ,INR 1.6 ,PTT 29.5 sec ,HOSPITAL COURSE: ,The patient received 1 liter normal saline and diltiazem (a total of 20 mg intravenously and 30 mg orally) in the emergency department. Emergency department personnel made several attempts to place a nasogastric tube for gastric lavage, but were unsuccessful. During her evaluation, the patient was noted to desaturate to 80% on room air, with an increase in her respiratory rate to 34 breaths per minute. She was administered 50% oxygen by nonrebreadier mask, with improvement in her oxygen saturation to 89%. Computed tomographic angiography was negative for pulmonary embolism.
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DESCRIPTION: Status post colonoscopy.  After discharge, experienced bloody bowel movements and returned to the emergency department for evaluation.

The situation involves a 73-year-old woman with a history of renal and bladder cancer, DVT, anticoagulation therapy, and recent surgery. She is experiencing bright red blood per rectum, indicating possible severe gastrointestinal bleeding, a potentially life-threatening condition. She presented with symptoms including generalized weakness, tachycardia, and respiratory distress, and required supplemental oxygen due to desaturation. The complexity and potential seriousness of her medical issues, combined with her age and recent history, suggest a high-stakes scenario where timely and effective medical intervention is crucial.


Medical Specialty: Letters
Sample Name: Letter - Dentistry

XYZ, S.,RE:  ABC,Dear Dr. XYZ,On your kind referral, I had the pleasure of meeting and consulting with ABC on MM/DD/YYYY for evaluation regarding extraction of his mandibular left second molar tooth #18.  This previously root-canaled tooth, now failed, is scheduled for removal.  As per your request, I agree that placement of an implant in the #20 and #19 positions would allow for immediate functional replacement of the bridge which has recently been lost in this area.,I have given Mr. ABC an estimate for the surgical aspects of this case and suggested he combine this with your prosthetic or restorative fees in order to have a full understanding of the costs involved with this process.,We will plan to place two Straumann implants as per our normal protocol, one each in the #19 and 20 positions, with the #19 implant being a wide-neck, larger diameter implant.  I will plan on providing the prosthetic abutments, the lab analogue, and temporary healing cap at the end of the four-month integration period.  If you have any additional suggestions or concerns, please give me a call.,Best regards,,
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DESCRIPTION: Letter on evaluation regarding extraction of mandibular left second molar tooth #18.

letters, molar tooth, extraction, mandibular, straumann, wide-neck, placement, positions, prosthetic, implant, tooth

The situation involves a routine dental procedure regarding the extraction of a tooth and the placement of dental implants. While dental surgeries can have complexities, the letter describes a relatively standard procedure with a clear treatment plan and coordination between professionals. There is no indication of urgent or life-threatening health risks involved, making it low-stakes.


Medical Specialty: Urology
Sample Name: Pyeloureteroscopy

PREOPERATIVE DIAGNOSES: , Left obstructed renal ureteropelvic junction obstruction status post pyeloplasty, percutaneous procedure, and pyeloureteroscopy x2, and status post Pseudomonas pyelonephritis x6, renal insufficiency, and solitary kidney.,POSTOPERATIVE DIAGNOSES:,  Left obstructed renal ureteropelvic junction obstruction status post pyeloplasty, percutaneous procedure, and pyeloureteroscopy x2, and status post Pseudomonas pyelonephritis x6, renal insufficiency, and solitary kidney.,PROCEDURE:  ,Cystoscopy under anesthesia, retrograde and antegrade pyeloureteroscopy, left ureteropelvic junction obstruction, difficult and open renal biopsy.,ANESTHESIA:  ,General endotracheal anesthetic with a caudal block x2.,FLUIDS RECEIVED:  ,1000 mL crystalloid.,ESTIMATED BLOOD LOSS:  ,Less than 10 mL.,SPECIMENS: , Tissue sent to pathology is a renal biopsy.,ABNORMAL FINDINGS: , A stenotic scarred ureteropelvic junction with dilated ureter and dilated renal pelvis.,TUBES AND DRAINS:  ,A 10-French silicone Foley catheter with 3 mL in balloon and a 4.7-French ureteral double J-stent multilength.,INDICATIONS FOR OPERATION:  ,The patient is a 3-1/2-year-old boy, who has a solitary left kidney with renal insufficiency with creatinine of 1.2, who has had a ureteropelvic junction repair performed by Dr. Chang.  It was subsequently obstructed with multiple episodes of pyelonephritis, two percutaneous tube placements, ureteroscopy with balloon dilation of the system, and continued obstruction.  Plan is for co surgeons due to the complexity of the situation and the solitary kidney to do surgical procedure to correct the obstruction.,DESCRIPTION OF OPERATION:  ,The patient was taken to the operative room.  Surgical consent, operative site, and patient identification were verified.  Dr. X and Dr. Y both agreed upon the procedures in advance.  Dr. Y then, once the patient was anesthetized, requested IV antibiotics with Fortaz, the patient had a caudal block placed, and he was then placed in lithotomy position.  Dr. Y then calibrated the urethra with the bougie a boule to 8, 10, and up to 12 French.  The 9.5-French cystoscope sheath was then placed within the patient's bladder with the offset scope, and his bladder had no evidence of cystitis.  I was able to locate the ureteral orifice bilaterally, although no urine coming from the right.  We then placed a 4-French ureteral catheter into the ureter as far as we could go.  An antegrade nephrostogram was then performed, which shows that the contrast filled the dilated pelvis, but did not go into the ureter.  A retrograde was performed, and it was found that there was a narrowed band across the two.  Upon draining the ureter allowing to drain to gravity, the pelvis which had been clamped and its nephrostomy tube did not drain at all.  Dr. Y then placed a 0.035 guidewire into the ureter after removing the 4-French catheter and then placed a 4.7-French double-J catheter into the ureter as far as it would go allowing it to coil in the bladder.  Once this was completed, we then removed the cystoscope and sheath, placed a 10-French Foley catheter, and the patient was positioned by Dr. X and Dr. Y into the flank position with the left flank up after adequate padding on the arms and legs as well as a brachial plexus roll.  He was then sterilely prepped and draped.  Dr. Y then incised the skin with a 15-blade knife through the old incision and then extended the incision with curved mosquito clamp and Dr. X performed cautery of the areas advanced to be excised.  Once this was then dissected, Dr. Y and Dr. X divided the lumbosacral fascia; at the latissimus dorsi fascia, posterior dorsal lumbotomy maneuver using the electrocautery; and then using curved mosquito clamps __________.  At this point, Dr. X used the cautery to enter the posterior retroperitoneal space through the posterior abdominal fascia.  Dr. Y then used the curved right angle clamp and dissected around towards the ureter, which was markedly adherent to the base of the retroperitoneum.  Dr. X and Dr. Y also needed dissection on the medial and lateral aspects with Dr. Y being on the lateral aspect of the area and Dr. X on the medial to get an adequate length of this.  The tissue was markedly inflamed and had significant adhesions noted.  The patient's spermatic vessels were also in the region as well as the renal vessels markedly scarred close to the ureteropelvic junction.  Ultimately, Dr. Y and Dr. X both with alternating dissection were able to dissect the renal pelvis to a position where Dr. Y put stay sutures and a 4-0 chromic to isolate the four quadrant area where we replaced the ureter.  Dr. X then divided the ureter and suture ligated the base, which was obstructed with a 3-0 chromic suture.  Dr. Y then spatulated the ureter for about 1.5 cm, and the stent was gently delivered in a normal location out of the ureter at the proximal and left alone in the bladder.  Dr. Y then incised the renal pelvis and dissected and opened it enough to allow the new ureteropelvic junction repair to be performed.  Dr. Y then placed interrupted sutures of 5-0 Monocryl at the apex to repair the most dependent portion of the renal pelvis, entered the lateral aspect, interrupted sutures of the repair.  Dr. X then was able to without much difficulty do interrupted sutures on the medial aspect.  The stent was then placed into the bladder in the proper orientation and alternating sutures by Dr. Y and Dr. X closed the ureteropelvic junction without any evidence of leakage.  Once this was complete, we removed the extra stay stitches and watched the ureter lay back into the retroperitoneum in a normal position without any kinking in apparently good position.  This opening was at least 1.5 cm wide.  Dr. Y then placed 2 stay sutures of 2-0 chromic in the lower pole of the kidney and then incised wedge biopsy and excised the biopsy with a 15-blade knife and curved iris scissors for renal biopsy for determination of renal tissue health.  Electrocautery was used on the base.  There was no bleeding, however, and the tissue was quite soft.  Dermabond and Gelfoam were placed, and then Dr. Y closed the biopsy site over with thrombin-Gelfoam using the 2-0 chromic stay sutures.  Dr. X then closed the fascial layers with running suture of 3-0 Vicryl in 3 layers.  Dr. Y closed the Scarpa fascia and the skin with 4-0 Vicryl and 4-0 Rapide respectively.  A 4-0 nylon suture was then placed by Dr. Y around the previous nephrostomy tube, which was again left clamped.  Dermabond tissue adhesive was placed over the incision and then a dry sterile dressing was placed by Dr. Y over the nephrostomy tube site, which was left clamped, and the patient then had a Foley catheter placed in the bladder.  The Foley catheter was then taped to his leg.  A second caudal block was placed for anesthesia, and he is in stable condition upon transfer to recovery room.
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DESCRIPTION: Cystoscopy under anesthesia, retrograde and antegrade pyeloureteroscopy, left ureteropelvic junction obstruction, difficult and open renal biopsy.

urology, cystoscopy, pyeloureteroscopy, ureteropelvic junction obstruction, pseudomonas pyelonephritis, renal insufficiency, fortaz, ureteropelvic junction repair, nephrostomy tube, renal biopsy, renal pelvis, foley catheter, ureteropelvic junction, renal, ureteropelvic,

The situation described involves a complex surgical procedure on a 3.5-year-old patient with a solitary kidney and renal insufficiency. Given the patient's medical history, including multiple previous procedures and infections, along with the complexity of the current surgery, this is a high-stakes situation. Correcting the obstruction is critical to preventing further renal damage or failure, which could have severe health implications for the child.


Medical Specialty: Emergency Room Reports
Sample Name: ER Report - Chest Pain

CHIEF COMPLAINT:, The patient complains of chest pain. ,HISTORY OF PRESENT ILLNESS: ,The patient is a 20-year-old male who states that he has had two previous myocardial infarctions related to his use of amphetamines. The patient has not used amphetamines for at least four to five months, according to the patient; however, he had onset of chest pain this evening. ,The patient describes the pain as midsternal pain, a burning type sensation that lasted several seconds. The patient took one of his own nitroglycerin tablets without any relief. The patient became concerned and came into the emergency department. ,Here in the emergency department, the patient states that his pain is a 1 on a scale of 1 to 10. He feels much more comfortable. He denies any shortness of breath or dizziness, and states that the pain feels unlike the pain of his myocardial infarction. The patient has no other complaints at this time. ,PAST MEDICAL HISTORY:, The patient's past medical history is significant for status post myocardial infarction in February of 1995 and again in late February of 1995. Both were related to illegal use of amphetamines. ,ALLERGIES:, None. ,CURRENT MEDICATIONS:, Include nitroglycerin p.r.n. ,PHYSICAL EXAMINATION: ,VITAL SIGNS: Blood pressure 131/76, pulse 50, respirations 18, temperature 96.5. ,GENERAL: The patient is a well-developed, well-nourished white male in no acute distress. The patient is alert and oriented x 3 and lying comfortably on the bed. ,HEENT: Atraumatic, normocephalic. The pupils are equal, round, and reactive. Extraocular movements are intact. ,NECK: Supple with full range of motion. No rigidity or meningismus. ,CHEST: Nontender. ,LUNGS: Clear to auscultation. ,HEART: Regular rate and rhythm. No murmur, S3, or S4. ,ABDOMEN: Soft, nondistended, nontender with active bowel sounds. No masses or organomegaly. No costovertebral angle tenderness. ,EXTREMITIES: Unremarkable. ,NEUROLOGIC: Unremarkable. ,EMERGENCY DEPARTMENT LABS:, The patient had a CBC, minor chemistry, and cardiac enzymes, all within normal limits. Chest x-ray, as read by me, was normal. Electrocardiogram, as read by me, showed normal sinus rhythm with no acute ST or T-wave segment changes. There were no acute changes seen on the electrocardiogram. O2 saturation, as interpreted by me, is 99%. ,EMERGENCY DEPARTMENT COURSE: ,The patient had a stable, uncomplicated emergency department course. The patient received 45 cc of Mylanta and 10 cc of viscous lidocaine with complete relief of his chest pain. The patient had no further complaints and stated that he felt much better shortly thereafter. ,AFTERCARE AND DISPOSITION: ,The patient was discharged from the emergency department in stable, ambulatory, good condition with instructions to use Mylanta for his abdominal pain and to follow up with his regular doctor in the next one to two days. Otherwise, return to the emergency department as needed for any problem. The patient was given a copy of his labs and his electrocardiogram. The patient was advised to decrease his level of activity until then. The patient left with final diagnosis of: ,FINAL DIAGNOSIS: ,1. Evaluation of chest pain. ,2. Possible esophageal reflux.
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DESCRIPTION: Patient complains of chest pain - possible esophageal reflux

This situation is relatively high-stakes due to the patient's history of multiple myocardial infarctions and the presence of chest pain, a symptom often associated with cardiac issues. Despite the patient's current stable condition and normal test results, chest pain in someone with his medical history requires careful consideration and follow-up to rule out any potential cardiac events. Moreover, the potential misattribution of chest pain to esophageal reflux when a cardiac issue might exist can have serious consequences. Therefore, the stakes are elevated due to these factors.


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

Medical Specialty: Ophthalmology
Sample Name: Phacoemulsification & Cataract Extraction - 1

PREOPERATIVE DIAGNOSIS: , Visually significant cataract, left eye.,POSTOPERATIVE DIAGNOSIS: , Visually significant cataract, left eye.,ANESTHESIA: , Topical/MAC.,PROCEDURE: , Phacoemulsification cataract extraction with intraocular lens implantation, left eye (Alcon AcrySof, SN60AT, 23.0 D, serial #***).,COMPLICATIONS: , None.,INDICATIONS FOR SURGERY:  ,The patient is a 74-year-old woman with complaints of painless progressive loss of vision in her left eye.  She was found to have a visually-significant cataract and, after discussion of the risks, benefits and alternatives to surgery, she elected to proceed with cataract extraction and lens implantation in this eye in efforts to improve her vision.,PROCEDURE IN DETAIL:  ,The patient was verified in the preoperative holding area and the informed consent was reviewed and verified to be on the chart.  They were transported to the operative suite, accompanied by the anesthesia service, where appropriate cardiopulmonary monitoring was established.  MAC anesthesia was achieved, which was followed by topical anesthesia using 1% preservative-free tetracaine eye drops.  The patient was prepped and draped in the usual fashion for sterile ophthalmic surgery and a lid speculum was placed.,Two stab-incision paracenteses were made in the cornea using the MVR blade, and the anterior chamber was irrigated with 1% preservative-free lidocaine for intracameral anesthesia.  The anterior chamber was filled with viscoelastic and a shelved, temporal, clear corneal incision was made using the diamond groove knife and steel keratome.  A continuous curvilinear capsulorrhexis was made in the anterior capsule using the bent-needle cystotome.  The lens nucleus was hydrodissected and hydrodelineated using balanced saline solution (BSS) on a Chang cannula until it rotated freely.,The phacoemulsification handpiece was introduced into the anterior chamber, and the lens nucleus was sculpted into 2 halves.  Each half was further subdivided with chopping and removed with phacoemulsification.  The remaining cortical material was removed with the irrigation and aspiration (I&A) handpiece.  The capsular bag was inflated with viscoelastic and the intraocular lens was injected into the capsule without difficulty.  The remaining viscoelastic was removed with the I&A handpiece, and the anterior chamber was filled to an appropriate intraocular pressure with BSS.  The corneal wounds were hydrated and verified to be water-tight.  Antibiotic ointment was placed, followed by a patch and shield.  The patient was transported to the PACU in good/stable condition.  There were no complications.  Followup is scheduled for tomorrow morning in the eye clinic.,A single interrupted 10-0 nylon suture was placed through the inferotemporal paracentesis to ensure that it was watertight at the end of the case.
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DESCRIPTION: Visually significant cataract, left eye.  Phacoemulsification cataract extraction with intraocular lens implantation, left eye.  The patient was found to have a visually-significant cataract and, after discussion of the risks, benefits and alternatives to surgery, she elected to proceed with cataract extraction and lens implantation in this eye in efforts to improve her vision.

ophthalmology, intraocular lens implantation, eye, intraocular lens, lens implantation, cataract extraction, cataract, intraocular, viscoelastic, handpiece, implantation, surgery, chamber, phacoemulsification, extraction, visually, anterior, lens

The scenario describes a routine cataract surgery with no complications reported, and the patient was stable post-surgery. Cataract surgery is a common procedure with a high success rate and relatively low risk, especially in cases without complications like this one. The patient is scheduled for a follow-up, which indicates standard postoperative care. Although surgery always carries some risk, given the context of a highly routine and straightforward operation with no complications, the stakes in this particular situation are low relative to other medical procedures.


Medical Specialty: Ophthalmology
Sample Name: Eye Examination - H&P

CHIEF COMPLAINT:,  This 26-year-old male presents today for a complete eye examination.,ALLERGIES:,  Patient admits allergies to aspirin resulting in disorientation, GI upset.,MEDICATION HISTORY:,  Patient is currently taking amoxicillin-clavulanate 125 mg-31.25 mg tablet, chewable medication was prescribed by A. General Practitioner MD, Adrenocot 0.5 mg tablet medication was prescribed by A. General Practitioner MD, Vioxx 12.5 mg tablet (BID).,PMH: , Past medical history is unremarkable.,PAST SURGICAL HISTORY:,  Patient admits past surgical history of (+) appendectomy in 1989.,SOCIAL HISTORY:,  Patient denies alcohol use.  Patient denies illegal drug use.  Patient denies STD history.  Patient denies tobacco use.,FAMILY HISTORY:,  Unremarkable.,REVIEW OF SYSTEMS:,Eyes: (-) dry eyes (-) eye or vision problems (-) blurred vision.,Constitutional Symptoms: (-) constitutional symptoms such as fever, headache, nausea, dizziness.,Musculoskeletal: (-) joint or musculoskeletal symptoms.,EYE EXAM:,  Patient is a pleasant, 26-year-old male in no apparent distress who looks his given age, is well developed and nourished with good attention to hygiene and body habitus.,Pupils:  Pupil exam reveals round and equally reactive to light and accommodation.,Motility:  Ocular motility exam reveals gross orthotropia with full ductions and versions bilateral.,Visual Fields:  Confrontation VF exam reveals full to finger confrontation O.U.,IOP:  IOP Method:  applanation tonometry OD:  10 mmHg Medications:  Alphagan; 0.2% Condition:  improving.,Keratometry:,OD:  K1 35.875K2 35.875,OS:  K1 35.875K2 41.875,Lids/Orbit:  Bilateral eyes reveal normal position without infection.  Bilateral eyelids reveals white and quiet.,Slit Lamp:  Corneal epithelium is intact with normal tear film and without stain.  Stroma is clear and avascular.  Corneal endothelium is smooth and of normal appearance.,Anterior Segment:  Bilateral anterior chambers reveal no cells or flare with deep chamber.,Lens:  Bilateral lenses reveals transparent lens that is in normal position.,Posterior Segment:  Posterior segment was dilated bilateral.  Bilateral retinas reveal normal color, contour, and cupping.,Retina:  Bilateral retinas reveals flat with normal vasculature out to the far periphery.  Bilateral retinas reveal normal reflex and color.,VISUAL ACUITY:,Visual acuity - uncorrected:  OD:  20/10 OS:  20/10 OU:  20/15.,REFRACTION:,Lenses - final:,OD:  +0.50 +1.50 X 125 Prism 1.75,OS:  +6.00 +3.50 X 125 Prism 4.00 BASE IN Fresnel,Add:  OD:  +1.00 OS:  +1.00,OU:  Far VA 20/25,TEST RESULTS:,  No tests to report at this time.,IMPRESSION:,  Eye and vision exam normal.,PLAN:,  Return to clinic in 12 month (s).,PATIENT INSTRUCTIONS:
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DESCRIPTION: Complete eye examination - Normal eye and vision exam.

The scenario described is a standard, routine eye examination with normal findings. The patient's eyes and vision are normal, and there are no acute issues, urgent medical needs, or complex medical management indicated. Routine follow-up is scheduled in 12 months, which is standard for a normal examination. The details provided indicate no immediate risks or high-stakes decisions involved in the current situation.


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

PROCEDURE PERFORMED: , Umbilical hernia repair.,PROCEDURE:,  After informed consent was obtained, the patient was brought to the operative suite and placed supine on the operating table.  The patient was sedated, and an adequate local anesthetic was administered using 1% lidocaine without epinephrine.  The patient was prepped and draped in the usual sterile manner.,A standard curvilinear umbilical incision was made, and dissection was carried down to the hernia sac using a combination of Metzenbaum scissors and Bovie electrocautery.  The sac was cleared of overlying adherent tissue, and the fascial defect was delineated.  The fascia was cleared of any adherent tissue for a distance of 1.5 cm from the defect.  The sac was then placed into the abdominal cavity and the defect was closed primarily using simple interrupted 0 Vicryl sutures.  The umbilicus was then re-formed using 4-0 Vicryl to tack the umbilical skin to the fascia.,The wound was then irrigated using sterile saline, and hemostasis was obtained using Bovie electrocautery.  The skin was approximated with 4-0 Vicryl in a subcuticular fashion.  The skin was prepped with benzoin, and Steri-Strips were applied.  A dressing was then applied.  All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently taken to the recovery room in good and stable condition.
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DESCRIPTION: Umbilical hernia repair. A standard curvilinear umbilical incision was made, and dissection was carried down to the hernia sac using a combination of Metzenbaum scissors and Bovie electrocautery.

urology, fascial defect, umbilical hernia repair, curvilinear umbilical, hernia sac, metzenbaum scissors, umbilical hernia, bovie electrocautery, electrocautery, hernia, incision, umbilical,

The procedure described is a standard surgical repair for an umbilical hernia, which is a common and relatively low-risk surgical operation. While all surgeries carry some level of risk, an umbilical hernia repair is generally considered routine and low-stakes compared to other more complex surgical procedures. The description indicates that the surgery was uneventful and the patient tolerated it well, further suggesting low risk in this specific situation.


Medical Specialty: Sleep Medicine
Sample Name: Polysomnography

PROCEDURE:,  The test was performed in an observed hospital laboratory.  The patient was monitored for EEG, EOG, jaw and leg EMG, thoracoabdominal impedance, oral/nasal thermistors, EKG, and oximetry.  The test was performed due to suspicion of sleep apnea and poor sleep quality with frequent awakenings.,The patient's height 6 feet, 1 inch and his weight 260 pounds.,DETAILS: , Total sleep period 377 minutes, total sleep time 241 minutes, sleep onset 33 minutes, and sleep efficiency 64%.  Stage I 9%, stage II 59%, stage III 23%, and REM stage 9%.  There were 306 apneas and hypopnea with apnea/hypopnea index 76.  Out of them 109 apneas and 197 hypopneas.  There were 40 arousals with index 9.9.  Mean oxygen saturation 91% with lowest oxygen saturation 70%.  A 19% of sleep time was spent with oxygen saturation less than 90% and 1% with less than 80%.  Oxygen saturation during awake 95%.  The patient slept in supine left side and right side, no preferred body position identified for apneas.  Average pulse 85 BPMs with lowest 61 and highest 116 BPMs.  No significant snoring throughout the study.  No significant leg jerk movement.,SUMMARY: , Severe obstructive sleep apnea with apnea/hypopnea index 76 and respiratory disturbance index 9.9.  Suggest weight loss, thyroid function evaluation, and CPAP titration study.
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DESCRIPTION: The patient was monitored for EEG, EOG, jaw and leg EMG, thoracoabdominal impedance, oral/nasal thermistors, EKG, and oximetry.  The test was performed due to suspicion of sleep apnea and poor sleep quality with frequent awakenings.

sleep medicine, thoracoabdominal impedance, oral/nasal thermistors, obstructive sleep apnea, titration study, eeg, eog, emgs, cpap, sleep,

The polysomnography results indicate severe obstructive sleep apnea, which is a potentially serious sleep disorder. This can lead to various health complications, including cardiovascular problems, daytime fatigue, and increased risk of accidents. Given the severity of the condition as reflected by the high apnea/hypopnea index and low oxygen saturation levels, this situation is considered high-stakes. Proper management and treatment are essential to prevent further health issues.


Medical Specialty: Pediatrics - Neonatal
Sample Name: Well-Child Check - 3

SUBJECTIVE:,  Patient presents with Mom for first visit to the office for two week well-child check.  Mom has no concerns stating that patient has been doing well overall since dismissal from the hospital.  Nursing every two to three hours with normal voiding and stooling pattern.  She does have a little bit of some gas and Mom has been using Mylicon drops which are helpful.  She is burping well, hiccuping, sneezing and burping appropriately.  Growth and development:  Denver II normal passing all developmental milestones per age in areas of fine motor, gross motor, personal and social interaction and speech and language development.  See Denver II form in the chart.,PAST MEDICAL HISTORY:,  Mom reports uncomplicated pregnancy and delivery with prenatal care provided by Dr. Hoing.  Delivery at Newton Medical Center at 39 weeks, 5 days gestation.  Birth weight was 3160 g.  Length 49.5 cm.  Head circumference 33 cm.  Infant was delivered to 22-year-old A-positive mom who is G1 P0, now P1.  Infant did well after delivery and was dismissed to home with Mom the following day.  No other hospitalizations.  No surgeries.,ALLERGIES: , None.,MEDICATIONS:,  Gas drops p.r.n.,FAMILY HISTORY: , Significant for cardiovascular problems and hypertension as well as diabetes mellitus on the maternal side of the family.  History of cancer and asthma on the paternal side of the family.  Mom unsure of what type of cancer.,SOCIAL HISTORY:,  Patient lives at home with 22-year-old mother Aubrey Mizel and her parents Bud and Sue Mizel in Newton, Kansas.  Father of the baby, Shivanka Silva age 30, is a full-time student at WSU in Wichita, Kansas and does help with care of the newborn.  There is no smoking in the home.  Family does have one pet dog in home.,REVIEW OF SYSTEMS:,  As per HPI; otherwise negative.,OBJECTIVE:,Vital Signs:  Weight 7 pounds, 1-1/5 ounces.  Height 21 inches.  Head circumference 35.8 cm.  Temperature 97.7.,General:  Well-developed, well-nourished, cooperative, alert and interactive 2-week-old female in no acute distress.,HEENT:  Atraumatic, normocephalic.  Anterior fontanel soft and flat.  Pupils equal, round and reactive.  Sclerae clear.  Red reflex present bilaterally.  TMs clear bilaterally.  Oropharynx:  Mucous membranes moist and pink.,Neck:  Supple, no lymphadenopathy.,Chest:  Clear to auscultation bilaterally.  No wheeze or crackles.  Good air exchange.,Cardiovascular:  Regular rate and rhythm.  No murmur.  Good pulses bilaterally.,Abdomen:  Soft, nontender.  Nondistended.  Positive bowel sounds.  No masses or organomegaly.  Healing umbilicus.,GU:  Tanner I female genitalia.  Femoral pulses equal bilaterally.  No rash.,Extremities:  Full range of motion.  No cyanosis, clubbing or edema.  Negative Ortolani and Barlow maneuver.,Back:  Straight.  No scoliosis.  Some increased pigment over the sacrum.,Integument:  Warm, dry and pink without lesions.,Neurological:  Alert.  Good muscle tone and strength.,ASSESSMENT/PLAN:,1. Well 2-week-old mixed race Caucasian and Middle Eastern descent female.,2. Anticipatory guidance for growth and diet development and safety issues as well as immunizations and visitation schedule.  Gave two week well-child check handout to Mom.  Plan follow up for the one month well-child check or as needed for acute care.  Mom will call for feeding problems, breathing problems or fever.  Otherwise, plan to see at one month.
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DESCRIPTION: A two week well-child check.

A two week well-child check.

The situation involves a routine well-child check for a 2-week-old infant, where the mother has no major concerns, and the infant is presenting as healthy and meeting all developmental milestones. The assessment indicates that the pediatrician considers the infant to be well and provides standard anticipatory guidance. In pediatrics, especially in neonatal care, missing or misjudging signs of potential health issues can have severe implications, but in this case, the issues mentioned are minor (like mild gas). Given that the child is stable and presenting no serious health warnings, the situation does not seem to be high-stakes.


Medical Specialty: Surgery
Sample Name: Sebaceous Cyst Excision

PREOPERATIVE DIAGNOSIS: , Sebaceous cyst, right lateral eyebrow.,POSTOPERATIVE DIAGNOSIS:,  Sebaceous cyst, right lateral eyebrow.,PROCEDURE PERFORMED: , Excision of sebaceous cyst, right lateral eyebrow.,ASSISTANT: , None.,ESTIMATED BLOOD LOSS: , Minimal.,COMPLICATIONS: , None.,ANESTHESIA: , General endotracheal anesthesia.,CONDITION OF THE PATIENT AT THE END OF THE PROCEDURE: , Stable.  Transferred to the recovery room.,INDICATIONS FOR PROCEDURE: , The patient is a 4-year-old with a history of sebaceous cyst.  The patient is undergoing PE tubes by Dr. X and I was asked to remove the cyst on the right lateral eyebrow.  I saw the patient in my clinic.  I explained to the mother in Spanish the risk and benefits.  Risk included but not limited to risk of bleeding, infection, dehiscence, scarring, need for future revision surgery.  We will proceed with the surgery.,PROCEDURE IN DETAIL: , The patient was taken into the operating room, placed in the supine position.  General anesthetic was administered.  A prophylactic dose of antibiotic was given.  The patient was prepped and draped in a usual manner.  The procedure began by infiltrating lidocaine with epinephrine around the cyst area.  Then, I proceeded with the help of a 15C blade to make an incision and remove a small wedge of tissue that includes a comedo point.  The incision was done superiorly then inferiorly to a full thickness and to the skin down to the cyst.  The cyst was detached of the surrounding structure with the help of blunt dissection.  Hemostasis was achieved with electrocautery.  The wound was closed with 5-0 Vicryl deep dermal interrupted stitches and Dermabond.  The patient tolerated the procedure well without complications and transferred to recovery room in stable condition.  I was present and participated in all aspects of the procedure.  Sponge, needle, and instrument counts were completed at the end of the procedure.
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DESCRIPTION: Excision of sebaceous cyst, right lateral eyebrow.

surgery, lateral eyebrow, excision of sebaceous cyst, sebaceous cyst, cyst, eyebrow, sebaceous,

The procedure described is a sebaceous cyst excision, which is generally considered a routine and low-risk surgical procedure. The patient's age (4 years old) and use of general anesthesia add some degree of risk, but there were no reported complications, blood loss was minimal, and the patient was stable post-surgery. The short note does not suggest any complex circumstances that would elevate the stakes significantly.