Medical Specialty: Consult - History and Phy.
Sample Name: Gen Med Consult - 8

SUBJECTIVE:,  The patient comes in today for a comprehensive evaluation.  She is well-known to me.  I have seen her in the past multiple times.,PAST MEDICAL HISTORY/SOCIAL HISTORY/FAMILY HISTORY: , Noted and reviewed today.  They are on the health care flow sheet.  She has significant anxiety which has been under fair control recently.  She has a lot of stress associated with a son that has some challenges.  There is a family history of hypertension and strokes.,CURRENT MEDICATIONS:,  Currently taking Toprol and Avalide for hypertension and anxiety as I mentioned.,REVIEW OF SYSTEMS:,  Significant for occasional tiredness.  This is intermittent and currently not severe.  She is concerned about the possibly of glucose abnormalities such diabetes.  We will check a glucose, lipid profile and a Hemoccult test also and a mammogram.  Her review of systems is otherwise negative.,PHYSICAL EXAMINATION:,VITAL SIGNS:  As above.,GENERAL:  The patient is alert, oriented, in no acute distress.,HEENT:  PERRLA.  EOMI.  TMs clear bilaterally.  Nose and throat clear.,NECK:  Supple without adenopathy or thyromegaly.  Carotid pulses palpably normal without bruit.,CHEST:  No chest wall tenderness.,BREAST EXAM:  No asymmetry, skin changes, dominant masses, nipple discharge, or axillary adenopathy.,HEART:  Regular rate and rhythm without murmur, clicks, or rubs.,LUNGS:  Clear to auscultation and percussion.,ABDOMEN:  Soft, nontender, bowel sounds normoactive.  No masses or organomegaly.,GU:  External genitalia without lesions.  BUS normal.  Vulva and vagina show just mild atrophy without any lesions.  Her cervix and uterus are within normal limits.  Ovaries are not really palpable.  No pelvic masses are appreciated.,RECTAL:  Negative.,BREASTS:  No significant abnormalities.,EXTREMITIES:  Without clubbing, cyanosis, or edema.  Pulses within normal limits.,NEUROLOGIC:  Cranial nerves II-XII intact.  Strength, sensation, coordination, and reflexes all within normal limits.,SKIN:  Noted to be normal.  No subcutaneous masses noted.,LYMPH SYSTEM:  No lymphadenopathy.,ASSESSMENT:,  Generalized anxiety and hypertension, both under fair control.,PLAN:,  We will not make any changes in her medications.  I will have her check a lipid profile as mentioned, and I will call her with that.  Screening mammogram will be undertaken.  She declined a sigmoidoscopy at this time.  I look forward to seeing her back in a year and as needed.
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DESCRIPTION: Comprehensive Evaluation - Generalized anxiety and hypertension, both under fair control.

This medical situation does not seem to involve an immediate threat to life or require urgent intervention. The patient's conditions are generalized anxiety and hypertension, both noted to be under fair control. The patient is under regular monitoring, and there are plans for standard tests and follow-up. There is no indication of acute or severe symptoms that require immediate medical intervention.


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

Medical Specialty: Gastroenterology
Sample Name: Esophagoscopy & Foreign Body Removal

PREOPERATIVE DIAGNOSIS: , Esophageal foreign body.,POSTOPERATIVE DIAGNOSIS:,  Esophageal foreign body, US penny.,PROCEDURE: , Esophagoscopy with foreign body removal.,ANESTHESIA: , General.,INDICATIONS: , The patient is a 17-month-old baby girl with biliary atresia, who had a delayed diagnosis and a late attempted Kasai portoenterostomy, which failed.  The patient has progressive cholestatic jaundice and is on the liver transplant list at ABCD.  The patient is fed by mouth and also with nasogastric enteral feeding supplements.  She has had an __________ cough and relatively disinterested in oral intake for the past month.  She was recently in the GI Clinic and an x-ray was ordered to check her tube placement and an incidental finding of a coin in the proximal esophagus was noted.  Based on the history, it is quite possible this coin has been there close to a month.  She is brought to the operating room now for attempted removal.  I met with the parents and talked to them at length about the procedure and the increased risk in a child with a coin that has been in for a prolonged period of time.  Hopefully, there will be no coin migration or significant irrigation that would require prolonged hospitalization.,OPERATIVE FINDINGS: , The patient had a penny lodged in the proximal esophagus in the typical location.  There was no evidence of external migration and surrounding irritation was noted, but did not appear to be excessive.  The coin actually came out with relative ease after which endoscopically identified.,DESCRIPTION OF OPERATION: , The patient came to the operating room and had induction of general anesthesia.  She was slow to respond to the usual propofol and other inducing agents and may be has some difficulty with tolerance or __________ tolerance to these medications.  After her endotracheal tube was placed and securely taped to the left side of her mouth, I positioned the patient with a prominent shoulder roll and neck hyperextension and then used the laryngoscope to elevate the tiny glottic mechanism.  A rigid esophagoscope was then inserted into the proximal esophagus, and the scope was gradually advanced with the lumen directly in frontal view.  This was facilitated by the nasoenteric feeding tube that was in place, which I followed carefully until the edge of the coin could be seen.  At this location, there was quite a bit of surrounding mucosal inflammation, but the coin edge could be clearly seen and was secured with the coin grasping forceps.  I then withdrew the scope, forceps, and the coin as one unit, and it was easily retrieved.  The patient tolerated the procedure well.  There were no intraoperative complications.  There was only one single coin noted, and she was awakened and taken to the recovery room in good condition.
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DESCRIPTION: Esophageal foreign body, US penny.  Esophagoscopy with foreign body removal.  The patient had a penny lodged in the proximal esophagus in the typical location.

gastroenterology, portoenterostomy, foreign body removal, proximal esophagus, coin, esophagoscopy, esophageal, esophagus,

The case involves a 17-month-old baby girl with a US penny lodged in the esophagus, requiring esophagoscopy for removal. The child has a complex medical history with biliary atresia and is on the liver transplant list, indicating compromised health. Although removal of the coin was successful and without complications, the situation is high-stakes due to the potential risks involved in operating on a child with existing health conditions and due to the prolonged presence of the coin, which could have led to serious complications such as infection or inflammation. Furthermore, the general anesthesia and management of a pediatric patient in this scenario increase the stakes.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Surgery
Sample Name: Pilon Fracture External Fixation

PREOP DIAGNOSES:,1.  Left pilon fracture.,2.  Left great toe proximal phalanx fracture.,POSTOP DIAGNOSES:,1.  Left pilon fracture.,2.  Left great toe proximal phalanx fracture.,OPERATION PERFORMED:,1.  External fixation of left pilon fracture.,2.  Closed reduction of left great toe, T1 fracture.,ANESTHESIA:  ,General.,BLOOD LOSS:  ,Less than 10 mL.,Needle, instrument, and sponge counts were done and correct.,DRAINS AND TUBES: , None.,SPECIMENS:,  None.,INDICATION FOR OPERATION:  ,The patient is a 58-year-old female who was involved in an auto versus a tree accident on 6/15/2009.  The patient suffered a fracture of a distal tibia and fibula as well as her great toe on the left side at that time.  The patient was evaluated by the emergency room and did undergo further evaluation due to loss of consciousness.  She underwent a provisional reduction and splinting in the emergency room followed by further evaluation for her heart and brain by the Medicine Service following this and she was appropriate for surgical intervention.  Due to the comminuted nature of her tibia fracture as well as soft tissue swelling, the patient is in need of a staged surgery with the 1st stage external fixation followed by open treatment and definitive plate and screw fixation.  The patient had swollen lower extremities, however, compartments were soft and she had no sign of compartment syndrome.  Risks and benefits of procedure were discussed in detail with the patient and her husband.  All questions were answered, and consent was obtained.  The risks including damage to blood vessels and nerves with painful neuroma or numbness, limb altered function, loss of range of motion, need for further surgery, infection, complex regional pain syndrome and deep vein thrombosis were all discussed as potential risks of the surgery.,FINDINGS:,1.  There was a comminuted distal tibia fracture with a fibular shaft fracture.  Following traction, there was adequate coronal and sagittal alignment of the fracture fragments and based on the length of the fibula, the fracture fragments were out to length.,2.  The base of her proximal phalanx fracture was assessed and reduced with essentially no articular step-off and approximately 1-mm displacement.  As the reduction was stable with buddy taping, no pinning was performed.,3.  Her compartments were full, but not firm nor did she have any sign of compartment syndrome and no compartment releases were performed.,OPERATIVE REPORT IN DETAIL:  ,The patient was identified in the preoperative holding area.  The left leg was identified and marked at the surgical site of the patient.  She was then taken to the operating room where she was transferred to the operating room in the supine position, placed under general anesthesia by the anesthesiology team.  She received Ancef for antibiotic prophylaxis.  A time-out was then undertaken verifying the correct patient, extremity, visibility of preoperative markings, availability of equipment, and administration of preoperative antibiotics.  When all was verified by the surgeon, anesthesia and circulating personnel left lower extremity was prepped and draped in the usual fashion.  At this point, intraoperative fluoroscopy was used to identify the fracture site as well as the appropriate starting point both in the calcaneus for a transcalcaneal cross stent and in the proximal tibia with care taken to leave enough room for later plate fixation without contaminating the future operative site.  A single centrally threaded calcaneal cross tunnel was then placed across the calcaneus parallel to the joint surface followed by placement of 2 Schantz pins in the tibia and a frame type external fixator was then applied in traction with attempts to get the fracture fragments out to length, but not overly distract the fracture and restore coronal and sagittal alignment as much as able.  When this was adequate, the fixator apparatus was locked in place, and x-ray images were taken verifying correct placement of the hardware and adequate alignment of the fracture.  Attention was then turned to the left great toe, where a reduction of the proximal phalanx fracture was performed and buddy taping as this provided good stability and was least invasive.  X-rays were taken showing good reduction of the base of the proximal phalanx of the great toe fracture.  At this point, the pins were cut short and capped to protect the sharp ends.  The stab wounds for the Schantz pin and cross pin were covered with gauze with Betadine followed by dry gauze, and the patient was then awakened from anesthesia and transferred to the progressive care unit in stable condition.  Please note there was no break in sterile technique throughout the case.,PLAN:  ,The patient will require definitive surgical treatment in approximately 2 weeks when the soft tissues are amenable to plate and screw fixation with decreased risk of wound complication.  She will maintain her buddy taping in regards to her great toe fracture.
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DESCRIPTION: External fixation of left pilon fracture and closed reduction of left great toe, T1 fracture.  Due to the comminuted nature of her tibia fracture as well as soft tissue swelling, the patient is in need of a staged surgery with the 1st stage external fixation followed by open treatment and definitive plate and screw fixation.

surgery, phalanx fracture, schantz pins, toe fracture, tibia fracture, pilon fracture, external fixation, proximal phalanx, fracture, toe, pilon, phalanx, reduction, tibia, proximal, fixation,

The situation involves a surgical operation following traumatic injuries from an auto accident, including a staged surgery approach for a complex tibia fracture. Surgical procedures are inherently high-stakes due to the risks of complications such as nerve damage, infection, and potential need for additional surgeries. The patient's condition after a traumatic event and the nature of the staged surgical treatment contribute to the high-stakes nature of this case.


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

PREOPERATIVE DIAGNOSIS: , Carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS: , Carpal tunnel syndrome.,TITLE OF PROCEDURE:  ,Open carpal tunnel release.,COMPLICATIONS:  ,None.,PROCEDURE IN DETAIL:  ,After administering appropriate antibiotics and general anesthesia the Left upper extremity was prepped and draped in the usual standard fashion.  The arm was exsanguinated with Esmarch, and the tourniquet inflated to 250 mmHg.,A longitudinal incision was made in line with the 4th ray.  The dissection was carried down to the superficial aponeurosis, which was cut.  The distal edge of the transverse carpal ligament was identified with a hemostat.  The hemostat was gently placed under the transverse carpal ligament to protect the contents of the carpal tunnel, and the ligament was cut on its ulnar side with a knife directly onto the hemostat.  The antebrachial fascia was cut proximally under direct vision with scissors.,After irrigating the wound with copious amounts of normal saline, the skin was repaired with 4-0 nylon interrupted stitches.,Marcaine with epinephrine was injected into the wound, which was then dressed and splinted.  The patient was sent to the recovery room in good condition, having tolerated the procedure well.
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DESCRIPTION: Carpal tunnel syndrome.  Open carpal tunnel release.  A longitudinal incision was made in line with the 4th ray.  The dissection was carried down to the superficial aponeurosis, which was cut.  The distal edge of the transverse carpal ligament was identified with a hemostat.

surgery, carpal ligament, carpal tunnel release, carpal tunnel syndrome, transverse carpal ligament, transverse, ligament, hemostat, tunnel, incision

The scenario describes a standard surgical procedure to relieve carpal tunnel syndrome, a common medical condition. The surgery itself is routine, with no complications reported, and the patient tolerated the procedure well, indicating a controlled and expected outcome. While all surgical procedures carry some level of risk and require precision, this particular surgery is generally considered low-risk with a high success rate. Therefore, the stakes are relatively low from a surgical standpoint.


Medical Specialty: Consult - History and Phy.
Sample Name: Consult - Atrial Fibrillation

REASON FOR CONSULTATION:,  Atrial fibrillation.,HISTORY OF PRESENT ILLNESS:,  The patient is a 78-year-old, Hispanic woman with past medical history significant for coronary artery disease status post bypass grafting surgery and history of a stroke with residual left sided hemiplegia.  Apparently, the patient is a resident of Lake Harris Port Square long-term facility after her stroke.  She was found to have confusion while in her facility.  She then came to the emergency room and found to have a right sided acute stroke.  12-lead EKG performed on August 10, 2009, found to have atrial fibrillation.  Telemetry also revealed atrial fibrillation with rapid ventricular response.  Currently, the telemetry is normal sinus rhythm.  Because of the finding of atrial fibrillation, cardiology was consulted.,The patient is a poor historian.  She did not recall why she is in the hospital, she said she had a stroke.  She reported no chest discomfort, no shortness of breath, no palpitations.,The following information was obtained from the patient's chart:,PAST MEDICAL HISTORY:,1.  Coronary artery disease status post bypass grafting surgery.  Unable to obtain the place, location, anatomy, and the year it was performed.,2.  Carotid artery stenosis status post right carotid artery stenting.  Again, the time was unknown.,3.  Diabetes.,4.  Hypertension.,5.  Hyperlipidemia.,6.  History of stroke with left side hemiplegia.,ALLERGIES: , No known drug allergies.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY:,  The patient is a resident of Lake Harris Port Square.  She has no history of alcohol use.,CURRENT MEDICATIONS: , Please see attached list including hydralazine, Celebrex, Colace, metformin, aspirin, potassium, Lasix, Levaquin, Norvasc, insulin, Plavix, lisinopril, and Zocor.,REVIEW OF SYSTEMS: , Unable to obtain.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Blood pressure 133/44, pulse 98, O2 saturation is 98% on room air.  Temperature 99, respiratory rate 16.,GENERAL:  The patient is sitting in the chair at bedside.  Appears comfortable.  Left facial droop.  Left side hemiplegia.,HEAD AND NECK:  No JVP seen.  Right side carotid bruit heard.,CHEST:  Clear to auscultation bilaterally.,CARDIOVASCULAR:  PMI not displaced, regular rhythm.  Normal S1 and S2.  Positive S4.  There is a 2/6 systolic murmur best heard at the left lower sternal border.,ABDOMEN:  Soft.,EXTREMITIES:  Not edematous.,DATA:,  A 12-lead EKG performed on August 9, 2009, revealed atrial fibrillation with a ventricular rate of 96 beats per minute, nonspecific ST wave abnormality.,Review of telemetry done the last few days, currently the patient is in normal sinus rhythm at the rate of 60 beats per minute.  Atrial fibrillation was noted on admission noted August 8 and August 10; however, there was normal sinus rhythm on August 10.,LABORATORY DATA: , WBC 7.2, hemoglobin 11.7.  The patient's hemoglobin was 8.2 a few days ago before blood transfusion.  Chemistry-7 within normal limits.  Lipid profile:  Triglycerides 64, total cholesterol 106, HDL 26, LDL 17.  Liver function tests are within normal limits.  INR was 1.1.,A 2D echo was performed on August 11, 2009, and revealed left ventricle normal in size with EF of 50%.  Mild apical hypokinesis.  Mild dilated left atrium.  Mild aortic regurgitation, mitral regurgitation, and tricuspid regurgitation.  No intracardiac masses or thrombus were noted.  The aortic root was normal in size.,ASSESSMENT AND RECOMMENDATIONS:,1.  Paroxysmal atrial fibrillation.  It is unknown if this is a new onset versus a paroxysmal atrial fibrillation.  Given the patient has a recurrent stroke, anticoagulation with Coumadin to prevent further stroke is indicated.  However, given the patient's current neurologic status, the safety of falling is unclear.  We need to further discuss with the patient's primary care physician, probably rehab physician.  If the patient's risk of falling is low, then Coumadin is indicated.  However, if the patient's risk for falling is high, then a course using aspirin and Plavix will be recommended.  Transesophageal echocardiogram probably will delineate possible intracardiac thrombus better, however will not change our current management.  Therefore, I will not recommend transesophageal echocardiogram at this point.  Currently, the patient's heart rate is well controlled, antiarrhythmic agent is not recommended at this point.,2.  Carotid artery stenosis.  The patient underwent a carotid Doppler ultrasound on this admission and found to have a high-grade increased velocity of the right internal carotid artery.  It is difficult to assess the severity of the stenosis given the history of possible right carotid stenting.  If clinically indicated, CT angio of the carotid will be indicated to assess for stent patency.  However, given the patient's current acute stroke, revascularization is not indicated at this time.,3.  Coronary artery disease.  Clinically stable.  No further test is indicated at this time.
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DESCRIPTION: Patient with past medical history significant for coronary artery disease status post bypass grafting surgery and history of a stroke with residual left sided hemiplegia.

The consultation involves a 78-year-old patient with a complex medical history, including coronary artery disease, stroke, diabetes, and newly found atrial fibrillation. The situation is high-stakes due to the risk factors associated with both recurrent strokes and atrial fibrillation, such as the need for careful management of anticoagulation therapy to prevent further strokes while balancing the risk of falls. The medical decisions made could have significant consequences on the patient's health outcomes, making it crucial for appropriate, timely medical management.


Medical Specialty: Sleep Medicine
Sample Name: Electroencephalogram - 1

REPORT:,  The electroencephalogram shows background activity at about 9-10 cycle/second bilaterally.  Little activity in the beta range is noted.  Waves of 4-7 cycle/second of low amplitude were occasionally noted.  Abundant movements and technical artifacts are noted throughout this tracing.  Hyperventilation was not performed.  Photic stimulation reveals no important changes.,CLINICAL INTERPRETATION:,  The electroencephalogram is essentially normal.
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DESCRIPTION: Electroencephalogram (EEG).  Photic stimulation reveals no important changes.  Essentially normal.

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

The situation involves reviewing the results of an electroencephalogram (EEG) test which is a common procedure in sleep medicine. The report indicates that the EEG is essentially normal, which suggests that there are no significant abnormalities or immediate health concerns. Typically, a normal EEG result is not considered high-stakes, as it suggests that the brain's electrical activity is functioning within normal parameters. There is no immediate threat to the patient's health or need for urgent intervention based on this report.


Medical Specialty: Surgery
Sample Name: Ear Cartilage Graft

PREOPERATIVE DIAGNOSES:  ,1.  Posttraumatic nasal deformity.,2.  Nasal obstruction.,3.  Nasal valve collapse.,4.  Request for cosmetic change with excellent appearance of nose.,POSTOPERATIVE DIAGNOSES:,1.  Posttraumatic nasal deformity.,2.  Nasal obstruction.,3.  Nasal valve collapse.,4.  Request for cosmetic change with excellent appearance of nose.,OPERATIVE PROCEDURES:,1.  Left ear cartilage graft.,2.  Repair of nasal vestibular stenosis using an ear cartilage graft.,3.  Cosmetic rhinoplasty.,4.  Left inferior turbinectomy.,ANESTHESIA: , General via endotracheal tube.,INDICATIONS FOR OPERATION: , The patient is with symptomatic nasal obstruction and fixed nasal valve collapse following a previous nasal fracture and attempted repair.  We discussed with the patient the indications, risks, benefits, alternatives, and complications of the proposed surgical procedure, she had her questions asked and answered.  Preoperative imaging was performed in consultation with regard to aesthetic results and communicated via the computerized imager.  The patient had questions asked and answered.  Informed consent was obtained.,PROCEDURE IN DETAIL: , The patient was taken to the operating room and placed in supine position.  The appropriate level of general endotracheal anesthesia was induced.  The patient was converted to the lounge chair position, and the nose was anesthetized and vasoconstricted in the usual fashion.  Procedure began with an inverted going incision and elevation of the skin of the nose in the submucoperichondrial plane over the medial crural footplates and lower lateral cartilages and up over the dorsum.  The septal angle was approached and submucoperichondrial flaps were elevated.  Severe nasal septal deviation to the right hand side and evidence of an old fracture with a separate alignment of the cartilaginous nose from the bony nose was encountered.  The upper laterals were divided and medial and lateral osteotomies were carried out.  Inadequate septal cartilage was noted to be present for use as spreader graft; therefore, left postauricular incision was made, and the conchal bowl cartilage graft was harvested, and it was closed with 3-0 running locking chromic with a sterile cotton ball pressure dressing applied.  Ear cartilage graft was then placed to put two spreader grafts on the left and one the right.  The two on the left extended all the way up to the caudal tip, the one on the right just primarily the medial wall.  It was placed in such a way to correct a caudal dorsal deviation of the nasal tip septum.  The upper lateral cartilage was noted to be of the same width and length in size.  Yet, the left lower cartilage was scarred and adherent to the upper lateral cartilage.  The upper lateral cartilages were noted to be excessive of uneven length with the right being much taller than the left and that was shortened to the same length.  The scar bands were released in the lower lateral cartilages to the upper lateral cartilages to allow free mobilization of the lower lateral cartilages.  A middle crus stitch was used to unite the domes, and then the nose was projected by suturing the medial crural footplates of the caudal septum in deep projected fashion.  Crushed ear cartilage was then placed in the pockets above the spreader grafts in the area of the deficient dorsal nasal height and the lateral nasal sidewall height.  The spreader brought an excellent aesthetic appearance to the nose.  We left more than 1 cm of dorsal and caudal support for the nasal tip and dorsum height.  Mucoperichondrial flaps were closed with 4-0 plain gut suture.  The skin was closed with 5-0 chromic and 6-0 fast absorbing gut.  Doyle splints were placed on each side of nasal septum and secured with 3-0 nylon and a Denver splint was applied.  The patient was awakened in the operating room and taken to the recovery room in good condition.
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DESCRIPTION: Left ear cartilage graft, repair of nasal vestibular stenosis using an ear cartilage graft, cosmetic rhinoplasty, left inferior turbinectomy.

surgery, nasal deformity, nasal obstruction, nasal valve, cartilage, cartilaginous, crural, graft, nasal fracture, postauricular, rhinoplasty, septal cartilage, submucoperichondrial, turbinectomy, vestibular, ear cartilage graft, posttraumatic nasal deformity, vestibular stenosis, ear cartilage, cartilage graft, cartilages, caudal, nasal, nose, obstruction, repair, stenosis

The surgical procedure described involves multiple complex surgeries such as cartilage grafting, rhinoplasty, and septal corrections under general anesthesia. These are significant surgical interventions with inherent risks including complications from anesthesia, potential for infection, bleeding, or dissatisfaction with cosmetic outcomes. There is also a mention of nasal obstruction which impacts breathing, adding a functional component to the stakes. Given the functional and aesthetic implications, alongside the surgical complexity and risks, this is a relatively high-stakes scenario.


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

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

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

The procedure described is a standard surgical operation for draining an ovarian cyst using minimally invasive techniques (laparoscopy). While surgery always carries some inherent risk, this type of procedure is quite routine and generally has a high success rate with low complication risks. The systematic and successful completion of the procedure further indicates low immediate stakes as the patient was stable and taken to recovery in good condition. Moreover, the operation did not reveal any unexpected findings or complications, which often would elevate the stakes.


Medical Specialty: Allergy / Immunology
Sample Name: Allergic Rhinitis

SUBJECTIVE:,  This 23-year-old white female presents with complaint of allergies.  She used to have allergies when she lived in Seattle but she thinks they are worse here.  In the past, she has tried Claritin, and Zyrtec.  Both worked for short time but then seemed to lose effectiveness.  She has used Allegra also.  She used that last summer and she began using it again two weeks ago.  It does not appear to be working very well.  She has used over-the-counter sprays but no prescription nasal sprays.  She does have asthma but doest not require daily medication for this and does not think it is flaring up.,MEDICATIONS: , Her only medication currently is Ortho Tri-Cyclen and the Allegra.,ALLERGIES: , She has no known medicine allergies.,OBJECTIVE:,Vitals:  Weight was 130 pounds and blood pressure 124/78.,HEENT:  Her throat was mildly erythematous without exudate.  Nasal mucosa was erythematous and swollen.  Only clear drainage was seen.  TMs were clear.,Neck:  Supple without adenopathy.,Lungs:  Clear.,ASSESSMENT:,  Allergic rhinitis.,PLAN:,1.  She will try Zyrtec instead of Allegra again.  Another option will be to use loratadine.  She does not think she has prescription coverage so that might be cheaper.,2.  Samples of Nasonex two sprays in each nostril given for three weeks.  A prescription was written as well.
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DESCRIPTION: A 23-year-old white female presents with complaint of allergies.

allergy / immunology, allergic rhinitis, allergies, asthma, nasal sprays, rhinitis, nasal, erythematous, allegra, sprays, allergic,

The situation involves a common medical condition, allergic rhinitis, that is typically not life-threatening or urgent. The patient has a plan for treatment, including trying different medications and considering cost-effective options. There are no immediate severe health risks or complications like anaphylaxis or severe asthma exacerbation indicated. Thus, it does not represent a high-stakes medical scenario.


Medical Specialty: Surgery
Sample Name: Cesarean Section & BTL

PREOPERATIVE DIAGNOSES:,1.  Term pregnancy.,2.  Desires permanent sterilization.,POSTOPERATIVE DIAGNOSES:,1.  Term pregnancy.,2.  Desires permanent sterilization.,PROCEDURE:,1.  Repeat low-transverse cesarean section.,2.  Bilateral tubal ligation.,3.  Extensive anterior abdominal wall/uterine/bladder adhesiolysis.,ANESTHESIA:,  Spinal/epidural with good effect.,FINDINGS:  ,Delivered vigorous male infant from cephalic presentation.  Apgars 9/9.  Birth weight 6 pounds 14 ounces.  Infant suctioned with a bulb upon delivery of the head and body.  Cord clamped and cut and infant passed to pediatric team present.  Complete placenta manually extracted intact with three vessel cord.  Extensive anterior abdominal wall adhesions with the anterior abdominal wall completely adhered to the anterior uterus throughout its entire length of the incision.  In addition, the bladder was involved in adhesion mass complex.  A window was developed surgically at the apical aspect of the incision enabling finger to pass to get behind the dense anterior abdominal wall adhesions.  These adhesions were surgically transected using Bovie cautery technique freeing up the anterior uterine attachment from the anterior abdominal wall.  Upon initial entry through the fibrous layer of the anterior abdominal wall _______ into the serosal and slightly muscular part of the anterior uterus due to the dense adhesion attachment that had occurred from previous surgeries.  Bilateral tubal ligation performed without difficulty via Parkland technique.,ESTIMATED BLOOD LOSS: , 500 mL.,COMPLICATIONS: , None.,URINE OUTPUT:  ,Per anesthesia records.  Urine cleared postoperatively.,IV FLUIDS:  ,Per anesthesia records.,The patient tolerated the procedure well and was taken to the recovery room in stable condition with stable vital signs.,OPERATIVE TECHNIQUE: , The patient was placed in a supine position after spinal/epidural anesthesia.  She was prepped and draped in the usual manner for repeat cesarean section.  A sharp knife was used to make a Pfannenstiel skin incision at the site of the previous scar.  This was carried through the subcutaneous tissue into the dense fibromuscular and fascial layer with a sharp knife.  This incision was extended laterally with Mayo scissors.  Dense fibromuscular layer was encountered from the patient's previous surgeries.  Upon entry, incision was entered into the serosal and partial muscular layer of the anterior uterus and there was no free area to enter into the peritoneal cavity due to dense fibromuscular adhesions of the entire uterus to the anterior abdominal wall at the length of the incision.  Fascia was previously separated superiorly and inferiorly from the muscular layer.  A surgical window was created at the apical aspect of the incision in the direction of the uterine fundus.  Finger was able to be passed and placed behind the dense adhesions between the uterus through anterior abdominal wall.  This adhesion complex was transacted via Bovie cautery its entire length circumferentially freeing the uterus from its attachment to anterior abdominal wall.  Inferiorly, difficulty was encountered with adhesion separation involving the bladder additionally to the uterus and the anterior abdominal wall.  These adhesions likewise were surgically transacted via sharp, blunt, and electrocautery dissection.  This was successfully done without anterior entry into the bladder.  Smooth pickups and Metzenbaum scissors were then used to do sharp dissection to separated the bladder from its attachment to the lower uterine segment enabling the vesicouterine peritoneal reflection for incision of the uterus.  The uterus was then incised using a sharp knife and low transverse incision.  This was extended with bandage scissors.  The infant was delivered easily from a cephalic presentation.  Bulb suction was done following delivery of the head and body.  The cord clamped and cut and the infant passed to pediatric team present.  Cord segment and cord blood was obtained.  Complete placenta manually extracted intact with three vessel cord.  Vigorous male infant, Apgars 9/9, weight 6 pounds 14 ounces.  Complete placenta with three vessels retrieved.  Uterus was exteriorized from the abdominal cavity.  Wet lap applied to the fundus and dry lap used to remove the remaining membranous tissue from the lining.  Pennington clamps placed at the uterine incision angles and the inferior incision lip.  A #1 chromic suture closed the uterus in running continuous interlocking closure.  Good hemostasis upon completion of the closure.  Laparotomy pads placed in the posterior cul-de-sac to remove any blood or clots.  The uterus was returned to the abdominal cavity, after using #1 chromic suture to close the anterior uterine incision, that was partial thickness through the serosal end of the muscular layer at midline adhesion.  This was closed with chromic suture in a running continuous interlocking closure with good hemostasis.  Attention was then focused on the bilateral tubal ligation.  Babcock clamp placed in the mid fallopian tube and elevated.  Cautery was used to make a window in the avascular segment of the mesosalpinx.  Proximal and distal #1 chromic suture ligation with mid fallopian tube transection performed.  The ligated proximal and distal stumps were then cauterized with Bovie cautery.  This tubal ligation procedure was done in a bilateral fashion.  Upon completion of tubal ligation, uterus was returned to the abdominal cavity.  Left and right gutters examined and found to be clean and dry.  Evaluation of the low uterine segment incision revealed continued hemostasis.  Oozing was encountered in the inferior bladder of dissection and 2-0 chromic suture in running continuous fashion, partial thickness of the bladder to control the oozing at this site was successfully done.  Interceed was then placed on the low uterine incision and the low anterior uterine aspect.  The midline rectus including peritoneum was re-approximated with simple interrupted chromic sutures.  Irrigation of the muscular layer with good hemostasis noted.  The fascia was closed with #1 Vicryl in a running continuous closure.  Subcutaneous tissue was irrigated, additional hemostasis with Bovie cautery.  The skin was closed with staples.
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DESCRIPTION: Repeat low-transverse cesarean section, bilateral tubal ligation (BTL), extensive anterior abdominal wall/uterine/bladder adhesiolysis.  Term pregnancy and desires permanent sterilization.

surgery, term pregnancy, sterilization, low-transverse cesarean section, bilateral tubal ligation, adhesiolysis, anterior uterus, abdominal cavity, cesarean section, chromic suture, tubal ligation, adhesions, uterus, abdominal, infant, anterior, cesarean, hemostasis, chromic, uterine,

The situation involves a repeat cesarean section (C-section) and a bilateral tubal ligation (BTL), both of which are surgical procedures with inherent risks. Additionally, the presence of extensive adhesions due to previous surgeries increases the complexity and risk of the operation. The surgical team must manage potential complications such as bleeding, injury to organs like the bladder, and ensure safe delivery of the infant. While C-sections and BTLs are relatively common procedures, the extensive adhesions elevate the stakes due to increased potential for complications. Furthermore, this is a high-profile medical procedure as it affects both the patient's and newborn's lives and health outcomes.


Medical Specialty: Consult - History and Phy.
Sample Name: Normal ROS Template - 3

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

consult - history and phy., review of systems, tinnitus, sinusitis, sore, mouth, hoarseness, goiter, heart, appetite, bowel, weakness, loss, swelling,

This interaction appears to be a routine consultation or review of systems for a patient with no notable complaints or medical history concerns. It is not associated with immediate medical decisions or emergencies, which are common indicators of high-stakes situations. The details provided are typical of a normal history intake process focusing on ensuring comprehensive documentation rather than addressing acute healthcare needs.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Fiberoptic Bronchoscopy - 1

PREOPERATIVE DIAGNOSIS:,1.  Hemoptysis.,2.  History of lung cancer.,POSTOPERATIVE DIAGNOSIS:,  Tumor occluding right middle lobe with friability.,PROCEDURE PERFORMED:,  Fiberoptic bronchoscopy, diagnostic.,LOCATION: , Endoscopy suite #4.,ANESTHESIA:,  General per Anesthesia Service.,ESTIMATED BLOOD LOSS: , Minimal.,COMPLICATIONS: , None.,INDICATIONS FOR PROCEDURE: , The patient presented to ABCD Hospital with a known history of lung cancer and acute hemoptysis with associated chest pain.  Due to her prior history, it was felt that she would benefit from diagnostic fiberoptic bronchoscopy to help determine the etiology of the hemoptysis.  She was brought to endoscopy suite #4 and informed consent was obtained.  ,PROCEDURE DETAILS:  ,The patient was placed in the supine position and intubated by the Anesthesia Service.  Intravenous sedation was given as per Anesthesia.  The fiberoptic scope was passed through the #8 endotracheal tube into the main trachea.  The right mainstem bronchus was examined.  The right upper lobe and subsegments appeared grossly within normal limits with no endobronchial lesions noted.  Upon examining the right middle lobe, there was a tumor noted occluding the lateral segment of the right middle lobe and a clot appreciated over the medial segment of the right middle lobe.,The clot was lavaged with normal saline and there was noted to be tumor behind this clot.  Tumor completely occluded both segments of the right middle lobe.  Scope was then passed to the subsegments of the right lower lobe, which were individually examined and noted to be grossly free of endobronchial lesions.  Scope was pulled back to the level of the midtrachea, passed into the left mainstem bronchus.  Left upper lobe and its subsegments were examined and noted to be grossly free of endobronchial lesions.  The lingula and left lower subsegments were all each individually examined and noted to be grossly free of endobronchial lesions.  There were some secretions noted throughout the left lung.  The scope was retracted and passed again to the right mainstem bronchus.  The area of the right middle lobe was reexamined.  The tumor was noted to be grossly friable with oozing noted from the tumor with minimal manipulation.  It did not appear as if a scope or cannula could be passed distal to the tumor.  Due to continued oozing, 1 cc of epinephrine was applied topically with adequate hemostasis obtained.  The area was examined for approximately one minute for assurance of adequate hemostasis.  The scope was then retracted and the patient was sent to the recovery room in stable condition.  She will be extubated as per the Anesthesia Service.  Cytology and cultures were not sent due to the patient's known diagnosis.  Further recommendations are pending at this time.
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DESCRIPTION: Fiberoptic bronchoscopy, diagnostic.  Hemoptysis and history of lung cancer.  Tumor occluding right middle lobe with friability.

cardiovascular / pulmonary, hemoptysis, lung cancer, tumor, fiberoptic, bronchoscopy, endoscopy suite, adequate hemostasis, fiberoptic bronchoscopy, endobronchial lesions, middle lobe, lobe,

The procedure described is a fiberoptic bronchoscopy on a patient with acute hemoptysis and a history of lung cancer. This procedure was necessary to investigate the cause of the hemoptysis, which was found to be a tumor occluding the right middle lobe. The stakes are high because the identification, management, and treatment of the tumor could significantly impact the patient's prognosis and quality of life. The potential for serious complications such as severe bleeding or airway obstruction also increases the stakes. However, the procedure was completed without complication and with minimal blood loss, leading to a stable postoperative condition.


Medical Specialty: Hematology - Oncology
Sample Name: Resection of Tumor of Scalp

PREOPERATIVE DIAGNOSIS: , Squamous cell carcinoma of the scalp.,POSTOPERATIVE DIAGNOSIS:,  Same.,OPERATION PERFORMED: , Radical resection of tumor of the scalp (CPT 11643).  Excision of tumor from the skull with debridement of the superficial cortex with diamond bur.  Advancement flap closure, with total undermined area 18 centimeters by 16 centimeters (CPT 14300).,ANESTHESIA:,  General endotracheal anesthesia.,INDICATIONS:  ,This is an 81-year-old male who has a large exophytic 7cm lesion of the anterior midline scalp which is biopsy-positive for skin malignancy, specifically, squamous call carcinoma.  This appears to be affixed to the underlying scalp.,PLAN: , Radical resection with frozen sections to clear margins thereafter, with planned reconstruction.,CONSENT:,  I have discussed with the patient the possible risks of bleeding, infection, renal problems, scar formation, injury to muscle, nerves, and possible need for additional surgery with possible recurrence of the patient's carcinoma, with review of detailed informed consent with the patient, who understood, and wished to proceed.,FINDINGS: , The patient had a 7cm large exophytic lesion which appeared to be invasive into the superficial table of the skull.  The final periosteal margin which centrally appeared was positive for carcinoma.  The final margins peripherally were all negative.,DESCRIPTION OF PROCEDURE IN DETAIL: , The patient was taken to the operating room and there was placed supine on the operating room table.,General endotracheal anesthesia was administered after endotracheal tube intubation was performed by the Anesthesia Service personnel.  The patient was thereafter prepped and draped in the usual sterile manner using Betadine Scrub and Betadine paint.  Thereafter, the local anesthesia was injected into the area around the tumor.  A **** type excision was planned down to the periosteum.  A supraperiosteal radical resection was performed.,It was obvious that there was tumor at the deep margin, involving the periosteum.  The edges were marked along the four quadrants, at the 12 o'clock, 3 o'clock, 6 o'clock, and the 9 o'clock positions, and these were sent for frozen section evaluation.  Frozen section revealed positive margins at one end of the resection.  Therefore, an additional circumferential resection was performed and the final margins were all negative.,Following completion, the deep periosteal margin was resected.  The circumferential periosteal margins were noted to be negative; however, centrally, there was a small area which showed tumor eroding into the superficial cortex of the skull.  Therefore, the Midas Rex drill was utilized to resect approximately 1-2 mm of the superficial cortex of the bone at the area where the positive margin was located.  Healthy bone was obtained; however, it did not enter the diploic or marrow-containing bone in the area.  Therefore, no bong margin was taken.  However, at the end of the procedure, it did not appear that the residual bone had any residual changes consistent with carcinoma.,Following completion of the bony resection, the area was irrigated with copious amounts of saline.  Thereafter, advancement flaps were created, both on the left and the right side of the scalp, with the total undermined area being approximately 18cm by 16cm.  The galea was incised in multiple areas, to provide for additional mobilization of the tissue.  The tissue was closed under tension with 3-0 Vicryl suture deep in the galea and surgical staples superficially.,The patient was awakened from anesthetic, was extubated and was taken to the recovery room in stable condition.,DISPOSITION:,  The patient was discharged to home with antibiotics and analgesics, to follow-up in approximately one week.,NOTE: , The final margins of both periosteal, as well as skin were negative circumferentially, around the tumor.  The only positive margin was deep, which was a periosteal margin and bone underlying it was partially resected, as was indicated above.
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DESCRIPTION: Radical resection of tumor of the scalp, excision of tumor from the skull with debridement of the superficial cortex with diamond bur, and advancement flap closure.

hematology - oncology, squamous cell carcinoma of the scalp, squamous cell carcinoma, radical resection, margin, midas rex drill, radical resection of tumor, resection of tumor, endotracheal anesthesia, superficial cortex, margins, periosteum, skull, cortex, periosteal, scalp, resection, tumor,

The situation involves the surgical removal of a large squamous cell carcinoma from the scalp of an elderly patient. The operation includes radical resection and requires careful management to ensure all cancerous tissue is removed while preserving surrounding tissue. The procedure carries potential risks such as bleeding, infection, nerve injury, and the need for further surgeries due to possible recurrence, making it a complex and critical medical scenario. Although the procedure was successful with negative margins post-surgery, the presence of cancer and the potential complications underscore the stakes involved.


Medical Specialty: Orthopedic
Sample Name: Cervical Spinal Stenosis

REASON FOR VISIT:  ,Followup cervical spinal stenosis.,HISTORY OF PRESENT ILLNESS:  ,Ms. ABC returns today for followup regarding her cervical spinal stenosis.  I have last seen her on 06/19/07.  Her symptoms of right greater than left upper extremity pain, weakness, paresthesias had been worsening after an incident on 06/04/07, when she thought she had exacerbated her conditions while lifting several objects.,I referred her to obtain a cervical spine MRI.,She returns today stating that she continues to have right upper extremity pain, paresthesias, weakness, which she believes radiates from her neck.  She had some physical therapy, which has been helping with the neck pain.  The right hand weakness continues.  She states she has a difficult time opening jars, and doors, and often drops items from her right greater than left upper extremity.  She states she have several occasions when she is sleeping at night, she has had sharp shooting radicular pain and weakness down her left upper extremity and she feels that these symptoms somewhat scare her.,She has been undergoing nonoperative management by Dr. X and feels this has been helping her neck pain, but not the upper extremity symptoms.,She denies any bowel and bladder dysfunction.  No lower back pain, no lower extremity pain, and no instability with ambulation.,REVIEW OF SYSTEMS:,  Negative for fevers, chills, chest pain, and shortness of breath.,FINDINGS:  ,On examination, Ms. ABC is a very pleasant well-developed, well-nourished female in no apparent distress.  Alert and oriented x3.  Normocephalic and atraumatic.  Afebrile to touch.,She ambulates with a normal gait.,Motor strength is 4 plus out of 5 in the bilateral deltoids, biceps, triceps muscle groups, 4 out of 5 in the bilateral hand intrinsic muscle groups, grip strength 4 out of 5, 4 plus out of 5 bilateral wrist extension and wrist flexion.,Light touch sensation decreased in the right greater than left C6 distribution.  Biceps and brachioradialis reflexes are 3 plus.  Hoffman sign normal bilaterally.,Lower extremity strength is 5 out of 5 in all muscle groups.  Patellar reflex is 3 plus.  No clonus.,Cervical spine radiographs dated 06/21/07 are reviewed.,They demonstrate evidence of spondylosis including degenerative disk disease and anterior and posterior osteophyte formation at C4-5, C5-6, C6-7, and C3-4 demonstrates only minimal if any degenerative disk disease.  There is no significant instability seen on flexion-extension views.,Updated cervical spine MRI dated 06/21/07 is reviewed.,It demonstrates evidence of moderate stenosis at C4-5, C5-6.  These stenosis is in the bilateral neural foramina and there is also significant disk herniation noted at the C6-7 level.  Minimal degenerative disk disease is seen at the C6-7.  This stenosis is greater than C5-6 and the next level is more significantly involved at C4-5.,Effacement of the ventral and dorsal CSF space is seen at C4-5, C5-6.,ASSESSMENT AND PLAN: , Ms. ABC's history, physical examination, and radiographic findings are compatible with C4-5, C5-6 cervical spinal stenosis with associated right greater than left upper extremity radiculopathy including weakness.,I spent a significant amount of time today with the patient discussing the diagnosis, prognosis, natural history, nonoperative, and operative treatment options.,I laid out the options as continued nonoperative management with physical therapy, the same with the addition of cervical epidural steroid injections and surgical interventions.,The patient states she would like to avoid injections and is somewhat afraid of having these done.  I explained to her that they may help to improve her symptoms, although they may not help with the weakness.,She feels that she is failing maximum nonoperative management and would like to consider surgical intervention.,I described the procedure consisting of C4-5, C5-6 anterior cervical decompression and fusion to the patient in detail on a spine model.,I explained the rationale for doing so including the decompression of the spinal cord and improvement of her upper extremity weakness and pain.  She understands.,I discussed the risks, benefits, and alternative of the procedure including material risks of bleeding, infection, neurovascular injury, dural tear, singular or multiple muscle weakness, paralysis, hoarseness of voice, difficulty swallowing, pseudoarthrosis, adjacent segment disease, and the risk of this given the patient's relatively young age.  Of note, the patient does have a hoarse voice right now, given the fact that she feels she has allergies.,I also discussed the option of disk arthroplasty.  She understands.,She would like to proceed with the surgery, relatively soon.  She has her birthday coming up on 07/20/07 and would like to hold off, until after then.  Our tentative date for the surgery is 08/01/07.  She will go ahead and continue the preoperative testing process.
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DESCRIPTION: Followup cervical spinal stenosis.  Her symptoms of right greater than left upper extremity pain, weakness, paresthesias had been worsening after an incident when she thought she had exacerbated her conditions while lifting several objects.

The patient is experiencing worsening symptoms of cervical spinal stenosis, which include significant pain, weakness, and paresthesias in the upper extremities. These symptoms are affecting her daily activities and causing her distress. Despite undergoing nonoperative management, her condition continues to deteriorate. The situation requires a decision on whether to proceed with surgical intervention, which comes with various risks such as bleeding, infection, nerve damage, and more. The upcoming surgical procedure, anterior cervical decompression and fusion, is a significant intervention that intends to alleviate her symptoms and prevent further deterioration. The stakes are relatively high due to the potential impact of the condition on the patient's quality of life, the complexities of the surgery, and the associated risks.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Atrial Flutter - Progress Note

HISTORY OF PRESENT ILLNESS: , Hospitalist followup is required for continuing issues with atrial flutter with rapid ventricular response, which was resistant to treatment with diltiazem and amiodarone, being followed by Dr. X of cardiology through most of the day.  This afternoon, when I am seeing the patient, nursing informs me that rate has finally been controlled with esmolol, but systolic blood pressures have dropped to the 70s with a MAP of 52.  Dr. X was again consulted from the bedside.  We agreed to try fluid boluses and then to consider Neo-Synephrine pressure support if this is not successful.  In addition, over the last 24 hours, extensive discussions have been held with the family and questions answered by nursing staff concerning the patient's possible move to Tahoe Pacific or a long-term acute care.  Other issues requiring following up today are elevated transaminases, continuing fever, pneumonia, resolving adult respiratory distress syndrome, ventilatory-dependent respiratory failure, hypokalemia, non-ST-elevation MI, hypernatremia, chronic obstructive pulmonary disease, BPH, atrial flutter, inferior vena cava filter, and diabetes.,PHYSICAL EXAMINATION,VITAL SIGNS:  T-max 103.2, blood pressure at this point is running in the 70s/mid 40s with a MAP of 52, heart rate is 100.,GENERAL:  The patient is much more alert appearing than my last examination of approximately 3 weeks ago.  He denies any pain, appears to have intact mentation, and is in no apparent distress.,EYES:  Pupils round, reactive to light, anicteric with external ocular motions intact.,CARDIOVASCULAR:  Reveals an irregularly irregular rhythm.,LUNGS:  Have diminished breath sounds but are clear anteriorly.,ABDOMEN:  Somewhat distended but with no guarding, rebound, or obvious tenderness to palpation.,EXTREMITIES:  Show trace edema with no clubbing or cyanosis.,NEUROLOGICAL:  The patient is moving all extremities without focal neurological deficits.,LABORATORY DATA: , Sodium 149; this is down from 151 yesterday.  Potassium 3.9, chloride 114, bicarb 25, BUN 35, creatinine 1.5 up from 1.2 yesterday, hemoglobin 12.4, hematocrit 36.3, WBC 16.5, platelets 231,000.  INR 1.4.  Transaminases are continuing to trend upwards of SGOT 546, SGPT 256.  Also noted is a scant amount of very concentrated appearing urine in the bag.,IMPRESSION: , Overall impressions continues to be critically ill 67-year-old with multiple medical problems probably still showing signs of volume depletion with hypotension and atrial flutter with difficult to control rate.,PLAN,1.  Hypotension.  I would aggressively try and fluid replete the patient giving him another liter of fluids.  If this does not work as discussed with Dr. X, we will start some Neo-Synephrine, but also continue with aggressive fluid repletion as I do think that indications are that with diminished and concentrated urine that he may still be down and fluids will still be required even if pressure support is started.,2.  Increased transaminases.  Presumably this is from increased congestion.  This is certainly concerning.  We will continue to follow this.  Ultrasound of the liver was apparently negative.,3.  Fever and elevated white count.  The patient does have a history of pneumonia and empyema.  We will continue current antibiotics per infectious disease and continue to follow the patient's white count.  He is not exceptionally toxic appearing at this time.  Indeed, he does look improved from my last examination.,4.  Ventilatory-dependent respiratory failure.  The patient has received a tracheostomy since my last examination.  Vent management per PMA.,5.  Hypokalemia.  This has resolved.  Continue supplementation.,6.  Hypernatremia.  This is improving somewhat.  I am hoping that with increased fluids this will continue to do so.,7.  Diabetes mellitus.  Fingerstick blood glucoses are reviewed and are at target.  We will continue current management.  This is a critically ill patient with multiorgan dysfunction and signs of worsening renal, hepatic, and cardiovascular function with extremely guarded prognosis.  Total critical care time spent today 37 minutes.
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DESCRIPTION: A critically ill 67-year-old with multiple medical problems probably still showing signs of volume depletion with hypotension and atrial flutter with difficult to control rate.

soap / chart / progress notes, rapid ventricular response, volume depletion, atrial flutter, atrial, hypotension, flutter,

The patient described is critically ill, with multiple serious medical conditions including atrial flutter with rapid ventricular response, hypotension, respiratory failure, possible liver congestion, renal issues, and infections. The case involves critical care management and potential life-threatening complications, indicating that the situation is high-stakes.


Medical Specialty: Hematology - Oncology
Sample Name: Symes Amputation - Hallux

PREOPERATIVE DIAGNOSES:,1.  Mass, left second toe.,2.  Tumor.,3.  Left hallux bone invasion of the distal phalanx.,POSTOPERATIVE DIAGNOSES:,1.  Mass, left second toe.,2.  Tumor.,3.  Left hallux with bone invasion of the distal phalanx.,PROCEDURE PERFORMED:,1.  Excision of mass, left second toe.,2.  Distal Syme's amputation, left hallux with excisional biopsy.,HISTORY: , This 47-year-old Caucasian male presents to ABCD General Hospital with a history of tissue mass on his left foot.  The patient states that the mass has been present for approximately two weeks and has been rapidly growing in size.  The patient also has history of shave biopsy in the past.  The patient does state that he desires surgical excision at this time.,PROCEDURE IN DETAIL:,  An IV was instituted by the Department of Anesthesia in the preoperative holding area.  The patient was transported from the operating room and placed on the operating room table in the supine position with the safety belt across his lap.  Copious amount of Webril was placed around the left ankle followed by a blood pressure cuff.  After adequate sedation by the Department of Anesthesia, a total of 6 cc mixed with 1% lidocaine plain with 0.5% Marcaine plain was injected in a digital block fashion at the base of the left hallux as well as the left second toe.,The foot was then prepped and draped in the usual sterile orthopedic fashion.  The foot was elevated from the operating table and exsanguinated with an Esmarch bandage.  Care was taken with the exsanguination to perform exsanguination below the level of the digits so as not to rupture the masses.  The foot was lowered to the operating table.  The stockinet was reflected and the foot was cleansed with wet and dry sponge.  A distal Syme's incision was planned over the distal aspect of the left hallux.  The incision was performed with a #10 blade and deepened with #15 down to the level of bone.  The dorsal skin flap was removed and dissected in toto off of the distal phalanx.  There was noted to be in growth of the soft tissue mass into the dorsal cortex with erosion in the dorsal cortex and exposure of cortical bone at the distal phalanx.  The tissue was sent to Pathology where Dr. Green stated that a frozen sample would be of less use for examining for cancer.  Dr. Green did state that he felt that there was an adequate incomplete excision of the soft tissue for specimen.  At this time, a sagittal saw was then used to resect all ends of bone of the distal phalanx.  The area was inspected for any remaining suspicious tissues.  Any suspicious tissue was removed.  The area was then flushed with copious amounts of sterile saline.  The skin was then reapproximated with #4-0 nylon with a combination of simple and vertical mattress sutures.,Attention was then directed to the left second toe.  There was noted to be a dorsolateral mass over the dorsal distal aspect of the left second toe.  A linear incision was made just medial to the tissue mass.  The mass was then dissected from the overlying skin and off of the underlying capsule.  This tissue mass was hard, round, and pearly-gray in appearance.  It does not invade into any other surrounding tissues.  The area was then flushed with copious amounts of sterile saline and the skin was closed with #4-0 nylon.  Dressings consisted of Owen silk soaked in Betadine, 4x4s, Kling, Kerlix, and an Ace wrap.  The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all five digits of the left foot.  The patient tolerated the above procedure and anesthesia well without complications.  The patient was transported to PACU with vital signs stable and vascular status intact.  The patient was given postoperative pain prescription for Vicodin and instructed to follow up with Dr. Bonnani in his office as directed.  The patient will be contacted immediately pending the results of pathology.  Cultures obtained in the case were aerobic and anaerobic gram stain, Silver stain, and a CBC.
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DESCRIPTION: Excision of mass, left second toe and distal Symes amputation, left hallux with excisional biopsy.  Mass, left second toe.  Tumor.  Left hallux bone invasion of the distal phalanx.

hematology - oncology, distal phalanx, mass, tumor., hallux bone, phalanx, symes amputation, excisional biopsy, distal, amputation, invasion, toe, symes, incision, flushed, excision, tissue, hallux

The described situation involves a surgical procedure for a patient with a rapidly growing mass on their foot, including tumor excision and bone involvement, which are common in cases of potential malignancy. The potential presence of cancer significantly raises the stakes due to its implications for the patient's health, prognosis, and treatment plan. Additionally, the procedure involves critical decisions and coordination among medical professionals, highlighting its complexity and the importance of accuracy and thoroughness. The stakes are heightened due to the need for accurate pathology results to inform further treatment decisions.


Medical Specialty: Surgery
Sample Name: D&C, Laparoscopy, & Salpingectomy

PREOPERATIVE DIAGNOSES:,1.  Pelvic pain.,2.  Ectopic pregnancy.,POSTOPERATIVE DIAGNOSES:,1.  Pelvic pain.,2.  Ectopic pregnancy.,3.  Hemoperitoneum.,PROCEDURES PERFORMED:,1.  Dilation and curettage (D&C).,2.  Laparoscopy.,3.  Right salpingectomy.,4.  Lysis of adhesions.,5.  Evacuation of hemoperitoneum.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS: , Scant from the operation, however, there was approximately 2 liters of clotted and old blood in the abdomen.,SPECIMENS:,  Endometrial curettings and right fallopian tube.,COMPLICATIONS: , None.,FINDINGS: , On bimanual exam, the patient has a small anteverted uterus, it is freely mobile.  No adnexal masses, however, were appreciated on the bimanual exam.  Laparoscopically, the patient had numerous omental adhesions to the vesicouterine peritoneum in the fundus of the uterus.  There were also adhesions to the left fallopian tube and the right fallopian tube.  There was a copious amount of blood in the abdomen approximately 2 liters of clotted and unclotted blood.  There was some questionable gestational tissue ________ on the left sacrospinous ligament.  There was an apparent rupture and bleeding ectopic pregnancy in the isthmus portion of the right fallopian tube.,PROCEDURE:,  After an informed consent was obtained, the patient was taken to the operating room and the general anesthetic was administered.  She was then positioned in the dorsal lithotomy position and prepped and draped in the normal sterile fashion.  Once the anesthetic was found to be adequate, a bimanual exam was performed under anesthetic.  A weighted speculum was then placed in the vagina.  The interior wall of vagina elevated with the uterine sound and the anterior lip of the cervix was grasped with the vulsellum tenaculum.  The cervix was then serially dilated with Hank dilators to a size #20 Hank and then a sharp curettage was performed obtaining a moderate amount of decidual appearing tissue and the tissue was then sent to pathology.  At this point, the uterine manipulator was placed in the cervix and attached to the anterior cervix and vulsellum tenaculum and weighted speculum were removed.  Next, attention was then turned to the abdomen.  The surgeons all are removed the dirty gloves in the previous portion of the case.  Next, a 2 cm incision was made immediately inferior to umbilicus.  The superior aspect of the umbilicus was grasped with a towel clamp and a Veress needle was inserted through this incision.  Next, a syringe was used to inject normal saline into the Veress needle.  The normal saline was seen to drop freely, so a Veress needle was connected to the CO2 gas which was started at its lowest setting.  The gas was seen to flow freely with normal resistance, so the CO2 gas was advanced to a higher setting.  The abdomen was insufflated to an adequate distension.  Once an adequate distention was reached, the CO2 gas was disconnected.  The Veress needle was removed and a size #11 step trocar was placed.  The introducer was removed and the trocar was connected to the CO2 gas and a camera was inserted.  Next, a 1 cm incision was made in the midline approximately two fingerbreadths below the pubic symphysis after transilluminating with the camera.  A Veress needle and a step sheath were inserted through this incision.  Next, the Veress needle was removed and a size #5 trocar was inserted under direct visualization.  Next a size #5 port was placed approximately five fingerbreadths to the left of the umbilicus in a similar fashion.  A size #12 port was placed in a similar fashion approximately six fingerbreadths to the right of the umbilicus and also under direct visualization.  The laparoscopic dissector was inserted through the suprapubic port and this was used to dissect the omental adhesions bluntly from the vesicouterine peritoneum and the bilateral fallopian tubes.  Next, the Dorsey suction irrigator was used to copiously irrigate the abdomen.  Approximate total of 3 liters of irrigation was used and the majority of all blood clots and free blood was removed from the abdomen.,Once the majority of blood was cleaned from the abdomen, the ectopic pregnancy was easily identified and the end of the fallopian tube was grasped with the grasper from the left upper quadrant and the LigaSure device was then inserted through the right upper quadrant with # 12 port.  Three bites with the LigaSure device were used to transect the mesosalpinx inferior to the fallopian tube and then transect the fallopian tube proximal to the ectopic pregnancy.  An EndoCatch bag was then placed to the size #12 port and this was used to remove the right fallopian tube and ectopic pregnancy.  This was then sent to the pathology.  Next, the right mesosalpinx and remains of the fallopian tube were examined again and they were seemed to be hemostatic.  The abdomen was further irrigated.  The liver was examined and appeared to be within normal limits.  At this point, the two size #5 ports and a size #12 port were removed under direct visualization.  The camera was then removed.  The CO2 gas was disconnected and the abdomen was desufflated.  The introducer was then replaced in a size #11 port and the whole port and introducer was removed as a single unit.  All laparoscopic incisions were closed with a #4-0 undyed Vicryl in a subcuticular interrupted fashion.  They were then steri-stripped and bandaged appropriately.  At the end of the procedure, the uterine manipulator was removed from the cervix and the patient was taken to Recovery in stable condition.  The patient tolerated the procedure well.  Sponge, lap, and needle counts were correct x2.  She was discharged home with a postoperative hemoglobin of 8.9.  She was given iron 325 mg to be taken twice a day for five months and Darvocet-N 100 mg to be taken every four to six hours for pain.  She will follow up within a week in the OB resident clinic.
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DESCRIPTION: Dilation and curettage (D&C), laparoscopy, right salpingectomy, lysis of adhesions, and evacuation of hemoperitoneum.  Pelvic pain, ectopic pregnancy, and hemoperitoneum.

surgery, pelvic pain, ectopic pregnancy, hemoperitoneum, d&c, dilation, laparoscopy, curettage, salpingectomy, lysis of adhesions, bimanual exam, veress needle, fallopian tube, umbilicus, cervix, ectopic, pregnancy, abdomen, tube,

The situation described involves a surgical procedure to address significant medical issues such as ectopic pregnancy and hemoperitoneum. These are potentially life-threatening conditions if not addressed quickly and appropriately. An ectopic pregnancy can lead to severe complications, including internal bleeding, which is evident from the substantial blood loss described during the procedure. Given the complexity and urgency of the situation, as well as the necessity of multiple surgical interventions, it is considered high-stakes. Successful intervention is critical for the patient's safety and recovery.


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

Medical Specialty: Orthopedic
Sample Name: Laminectomy & Foraminotomy Revision

PREOPERATIVE DIAGNOSES:,1.  Recurrent spinal stenosis at L3-L4, L4-L5, and L5-S1.,2.  Spondylolisthesis, which is unstable at L4-L5.,3.  Recurrent herniated nucleus pulposus at L4-L5 bilaterally.,POSTOPERATIVE DIAGNOSES:,1.  Recurrent spinal stenosis at L3-L4, L4-L5, and L5-S1.,2.  Spondylolisthesis, which is unstable at L4-L5.,3.  Recurrent herniated nucleus pulposus at L4-L5 bilaterally.,PROCEDURE PERFORMED:,1.  Microscopic-assisted revision of bilateral decompressive lumbar laminectomies and foraminotomies at the levels of L3-L4, L4-L5, and L5-S1.,2.  Posterior spinal fusion at the level of L4-L5 and L5-S1 utilizing local bone graft, allograft and segmental instrumentation.,3.  Posterior lumbar interbody arthrodesis utilizing cage instrumentation at L4-L5 with local bone graft and allograft.  All procedures were performed under SSEP, EMG, and neurophysiologic monitoring.,ANESTHESIA: , General via endotracheal tube.,ESTIMATED BLOOD LOSS:  ,Approximately 1000 cc.,CELL SAVER RETURNED:  ,Approximately 550 cc.,SPECIMENS: , None.,COMPLICATIONS: , None.,DRAIN: , 8-inch Hemovac.,SURGICAL INDICATIONS: , The patient is a 59-year-old male who had severe disabling low back pain.  He had previous lumbar laminectomy at L4-L5.  He was noted to have an isthmic spondylolisthesis.,Previous lumbar laminectomy exacerbated this condition and made it further unstable.  He is suffering from neurogenic claudication.  He was unresponsive to extensive conservative treatment.  He has understanding of the risks, benefits, potential complications, treatment alternatives and provided informed consent.,OPERATIVE TECHNIQUE: , The patient was taken to OR #5 where he was given general anesthetic by the Department of Anesthesia.  He was subsequently placed prone on the Jackson's spinal table with all bony prominences well padded.  His lumbar spine was then sterilely prepped and draped in the usual fashion.  A previous midline incision was extended from approximate level of L3 to S1.  This was in the midline.  Skin and subcutaneous tissue were debrided sharply.  Electrocautery provided hemostasis.  ,Electrocautery was utilized to dissect through subcutaneous tissue of lumbar fascia.  The lumbar fascia was identified and split in the midline.  Subperiosteal dissection was then carried out with electrocautery and ______ elevated from the suspected levels of L3-S1.  Once this was exposed, the transverse processes, a Kocher clamp was placed and a localizing cross-table x-ray confirmed the interspace between the spinous processes of L3-L4.  Once this was completed, a self-retaining retractor was then placed.  With palpation of the spinous processes, the L4 posterior elements were noted to be significantly loosened and unstable.  These were readily mobile with digital palpation.  A rongeur was then utilized to resect the spinous processes from the inferior half of L3 to the superior half of S1.  This bone was morcellized and placed on the back table for utilization for bone grafting.  The rongeur was also utilized to thin the laminas from the inferior half of L3 to superior half of S1.  Once this was undertaken, the unstable posterior elements of L4 were meticulously dissected free until wide decompression was obtained.  Additional decompression was extended from the level of the inferior half of L3 to the superior half of S1.  The microscope was utilized during this portion of procedure for visualization.  There was noted to be no changes during the decompression portion or throughout the remainder of the surgical procedure.  Once decompression was deemed satisfactory, the nerve roots were individually inspected and due to the unstable spondylolisthesis, there was noted to be tension on the L4 and L5 nerve roots crossing the disc space at L4-L5.  Once this was identified, foraminotomies were created to allow additional mobility.  The wound was then copiously irrigated with antibiotic solution and suctioned dry.  Working type screws, provisional titanium screws were then placed at L4-l5.  This was to allow distraction and reduction of the spondylolisthesis.  These were placed in the pedicles of L4 and L5 under direct intensification.  The position of the screws were visualized, both AP and lateral images.  They were deemed satisfactory.,Once this was completed, a provisional plate was applied to the screws and distraction applied across L4-L5.  This allowed for additional decompression of the L5 and L4 nerve roots.  Once this was completed, the L5 nerve root was traced and deemed satisfactory exiting neural foramen after additional dissection and discectomy were performed.  Utilizing a series of interbody spacers, a size 8 mm spacer was placed within the L4-L5 interval.  This was taken in sequence up to a 13 mm space.  This was then reduced to a 11 mm as it was much more anatomic in nature.  Once this was completed, the spacers were then placed on the left side and distraction obtained.  Once the distraction was obtained to 11 mm, the interbody shavers were utilized to decorticate the interbody portion of L4 and L5 bilaterally.  Once this was taken to 11 mm bilaterally, the wound was copiously irrigated with antibiotic solution and suction dried.  A 11 mm height x 9 mm width x 25 mm length carbon fiber cages were packed with local bone graft and Allograft.  There were impacted at the interspace of L4-L5 under direct image intensification.  Once these were deemed satisfactory, the wound was copiously irrigated with antibiotic solution and suction dried.  The provisional screws and plates were removed.  This allowed for additional compression along L4-L5 with the cage instrumentation.  Permanent screws were then placed at L4, L5, and S1 bilaterally.  This was performed under direct image intensification.  The position was verified in both AP and lateral images.  Once this was completed, the posterolateral gutters were decorticated with an AM2 Midas Rex burr down to bleeding subchondral bone.  The wound was then copiously irrigated with antibiotic solution and suction dried.  The morcellized Allograft and local bone graft were mixed and packed copiously from the transverse processes of L4-S1 bilaterally.  A 0.25 inch titanium rod was contoured of appropriate length to span from L4-S1.  Appropriate cross connecters were applied and the construct was placed over the pedicle screws.  They were tightened and sequenced to allow additional posterior reduction of the L4 vertebra.  Once this was completed, final images in the image intensification unit were reviewed and were deemed satisfactory.  All connections were tightened and retightened in Torque 2 specifications.  The wound was then copiously irrigated with antibiotic solution and suction dried.  The dura was inspected and noted to be free of tension.  At the conclusion of the procedure, there was noted to be no changes on the SSEP, EMG, and neurophysiologic monitors.  An 8-inch Hemovac drain was placed exiting the wound.  The lumbar fascia was then approximated with #1 Vicryl in interrupted fashion, the subcutaneous tissue with #2-0 Vicryl interrupted fashion, surgical stainless steel clips were used to approximate the skin.  The remainder of the Hemovac was assembled.  Bulky compression dressing utilizing Adaptic, 4x4, and ABDs was then affixed to the lumbar spine with Microfoam tape.  He was turned and taken to the recovery room in apparent satisfactory condition.  Expected surgical prognosis remains guarded.
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DESCRIPTION: Microscopic-assisted revision of bilateral decompressive lumbar laminectomies and foraminotomies at the levels of L3-L4, L4-L5, and L5-S1.  Posterior spinal fusion at the level of L4-L5 and L5-S1 utilizing local bone graft, allograft and segmental instrumentation.  Posterior lumbar interbody arthrodesis utilizing cage instrumentation at L4-L5 with local bone graft and allograft.  All procedures were performed under SSEP, EMG, and neurophysiologic monitoring.

The situation involves a complex orthopedic surgical procedure, specifically a revision surgery for a patient with unstable spondylolisthesis, recurrent spinal stenosis, and other spinal issues. Spinal surgeries are generally high-stakes due to the potential for significant complications, the involvement of critical structures such as nerve roots, and the need for precise execution to avoid adverse outcomes like paralysis or persistent pain. The stakes are heightened by the patient's history of previous surgeries and unresponsive conservative treatments, indicating that this surgery is a critical measure for improving quality of life. The complexity of the surgery, as well as the potential for serious complications, contribute to it being a high-stakes situation.


Medical Specialty: Surgery
Sample Name: Flex Sig - 2

PROCEDURE IN DETAIL: , Following a barium enema prep and lidocaine ointment to the rectal vault, perirectal inspection and rectal exam were normal.  The Olympus video colonoscope then introduced into the rectum and passed by directed vision to the distal descending colon.  Withdrawal notes an otherwise normal descending, rectosigmoid and rectum.  Retroflexion noted no abnormality of the internal ring.  No hemorrhoids were noted.  Withdrawal from the patient terminated the procedure.
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DESCRIPTION: Flexible sigmoidoscopy.  The Olympus video colonoscope then introduced into the rectum and passed by directed vision to the distal descending colon.

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

The procedure described is a flexible sigmoidoscopy. This is a routine medical procedure typically used for screening and diagnostic purposes in the colon and rectum, particularly to look for signs of colorectal cancer or other abnormalities. While medical procedures always carry some level of risk, a flexible sigmoidoscopy is generally considered low-risk and routine. No complications or abnormal findings were noted, which further reduces the stakes of this situation. Therefore, this procedure is not considered high-stakes, as it does not involve immediate life-threatening conditions or urgent decision-making.


Medical Specialty: Pediatrics - Neonatal
Sample Name: Circumcision - Infant

PROCEDURE: , Circumcision.,PRE-PROCEDURE DIAGNOSIS: , Normal male phallus.,POST-PROCEDURE DIAGNOSIS: , Normal male phallus.,ANESTHESIA:  ,1% lidocaine without epinephrine.,INDICATIONS: , The risks and benefits of the procedure were discussed with the parents.  The risks are infection, hemorrhage, and meatal stenosis.  The benefits are ease of care and cleanliness and fewer urinary tract infections.  The parents understand this and have signed a permit.,FINDINGS: , The infant is without evidence of hypospadias or chordee prior to the procedure.,TECHNIQUE:  ,The infant was given a dorsal penile block with 1% lidocaine without epinephrine using a tuberculin syringe and 0.5 cc of lidocaine was delivered subcutaneously at 10:30 and at 1:30 o'clock at the dorsal base of the penis.,The infant was prepped then with Betadine and draped with a sterile towel in the usual manner.  Clamps were placed at 10 o'clock and 2 o'clock and the adhesions between the glans and mucosa were instrumentally lysed.  Dorsal hemostasis was established and a dorsal slit was made.  The foreskin was fully retracted and remaining adhesions between the glans and mucosa were manually lysed.  The infant was fitted with a XX-cm Plastibell.  The foreskin was retracted around the Plastibell and circumferential hemostasis was established.  The excess foreskin was removed with scissors and the infant tolerated the procedure well with a minimum amount of blood loss.  Instructions for continuing care are to watch for any evidence of hemorrhage or urination and the parents are instructed in the care of the circumcised penis.
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DESCRIPTION: Circumcision.  Normal male phallus.   The infant is without evidence of hypospadias or chordee prior to the procedure.

pediatrics - neonatal, dorsal slit, hypospadias, chordee, epinephrine, hemorrhage, penis, adhesions, circumcision, phallus, lidocaine, foreskin, infant

The procedure described is an infant circumcision, which is a common and generally low-risk surgical procedure when performed by trained medical professionals. Although it has associated risks like any surgical procedure, such as infection or hemorrhage, these are relatively rare, and the procedure is regularly performed safely in clinical settings. The parental consent has been obtained, and the described technique shows adherence to sterile procedures. However, while it is common, it involves ethical considerations and ongoing debates regarding necessity which may heighten perceived stakes for some parents. Still, in terms of medical risk, it is not extremely high-stakes.


Medical Specialty: Urology
Sample Name: Penile Skin Bridges Excision

PREOPERATIVE DIAGNOSIS: , Penile skin bridges after circumcision.,POSTOPERATIVE DIAGNOSIS: , Penile skin bridges after circumcision.,PROCEDURE:  ,Excision of penile skin bridges about 2 cm in size.,ABNORMAL FINDINGS:  ,Same as above.,ANESTHESIA:  ,General inhalation anesthetic with caudal block.,FLUIDS RECEIVED: , 300 mL of crystalloids.,ESTIMATED BLOOD LOSS: , Less than 5 mL.,SPECIMENS: , No tissue sent to Pathology.,TUBES AND DRAINS:,  No tubes or drains were used.,COUNT: , Sponge and needle counts were correct x2.,INDICATIONS FOR OPERATION:  ,The patient is a 2-1/2-year-old boy with a history of newborn circumcision who developed multiple skin bridges after circumcision causing curvature with erection.  Plan is for repair.,DESCRIPTION OF PROCEDURE: , The patient is taken to the operating room, where surgical consent, operative site, and the patient's identification was verified.  Once he was anesthetized, the caudal block was placed and IV antibiotics were given.  He was then placed in a supine position and sterilely prepped and draped.  Once he was prepped and draped, we used a straight mosquito clamp and went under the bridges and crushed them, and then excised them with a curved iris and curved tenotomy scissors.  We removed the excessive skin on the shaft skin and on the glans itself.  We then on the ventrum excised the bridge and did a Heinecke-Mikulicz closure with interrupted figure-of-eight and interrupted suture of 5-0 chromic.  Electrocautery was used for hemostasis.  Once this was done, we then used Dermabond tissue adhesive and Surgicel to prevent the bridges from returning again.  IV Toradol was given at the end of procedure.  The patient tolerated the procedure well, was in stable condition upon transfer to the recovery room.
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DESCRIPTION: Excision of penile skin bridges about 2 cm in size.

urology, heinecke-mikulicz, penile skin bridges, caudal block, penile skin, skin bridges, excision, circumcision, penile,

The procedure described, excision of penile skin bridges, is a standard surgical treatment for complications arising from circumcision. Given the minimal estimated blood loss and the use of general anesthesia, it is not a high-risk procedure. The child’s stable postoperative condition also indicates this is a routine surgical intervention. The stakes are not negligible, as any surgical procedure on a child involves some level of risk, but the stakes are not extremely high due to the routine nature and low complexity of the surgery.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Lung Cancer & MI - Hospice Cosult

REASON FOR CONSULT: , I was asked to see this patient with metastatic non-small-cell lung cancer, on hospice with inferior ST-elevation MI.,HISTORY OF PRESENT ILLNESS: , The patient from prior strokes has expressive aphasia, is not able to express herself in a clear meaningful fashion.  Her daughter who accompanies her is very attentive whom I had met previously during drainage of a malignant hemorrhagic pericardial effusion last month.  The patient has been feeling well for the last several weeks, per the daughter, but today per the personal aide, became agitated and uncomfortable at about 2:30 p.m.  At about 7 p.m., the patient began vomiting, was noted to be short of breath by her daughter with garbled speech, arms flopping, and irregular head movements.  Her daughter called 911 and her symptoms seemed to improve.  Then, she began vomiting.  When the patient's daughter asked her if she had chest pain, the patient said yes.,She came to the emergency room, an EKG showed inferior ST-elevation MI.  I was called immediately and knowing her history, especially, her hospice status with recent hemorrhagic pericardial effusion, I felt thrombolytic was contraindicated and she would not be a candidate for aggressive interventional therapy with PCI/CABG.  She was begun after discussion with the oncologist, on heparin drip and has received morphine, nitro, and beta-blocker, and currently states that she is pain free.  Repeat EKG shows normalization of her ST elevation in the inferior leads as well as normalization of prior reciprocal changes.,PAST MEDICAL HISTORY: , Significant for metastatic non-small-cell lung cancer.  In early-to-mid December, she had an admission and was found to have a malignant pericardial effusion with tamponade requiring urgent drainage.  We did repeat an echo several weeks later and that did not show any recurrence of the pericardial effusion.  She is on hospice from the medical history, atrial fibrillation, hypertension, history of multiple CVA.,MEDICATIONS: , Medications as an outpatient:,1.  Amiodarone 200 mg once a day.,2.  Roxanol concentrate 5 mg three hours p.r.n. pain.,ALLERGIES:  ,CODEINE.  NO SHRIMP, SEAFOOD, OR DYE ALLERGY.,FAMILY HISTORY: , Negative for cardiac disease.,SOCIAL HISTORY: , She does not smoke cigarettes.  She uses alcohol.  No use of illicit drugs.  She is divorced and lives with her daughter.  She is a retired medical librarian from Florida.,REVIEW OF SYSTEMS:  ,Unable to be obtained due to the patient's aphasia.,PHYSICAL EXAMINATION: , Height 5 feet 3, weight of 106 pounds, temperature 97.1 degrees, blood pressure ranges from 138/82 to 111/87, pulse 61, respiratory rate 22.  O2 saturation 100%.  On general exam, she is an elderly woman with now marked aphasia, which per her daughter waxes and wanes, was more pronounced and she nods her head up and down when she says the word, no, and conversely, she nods her head side-to-side when she uses the word yes with some discordance in her head gestures with vocalization.  HEENT shows the cranium is normocephalic and atraumatic.  She has dry mucosal membrane.  She now has a right facial droop, which per her daughter is new.  Neck veins are not distended.  No carotid bruits visible.  Skin:  Warm, well perfused.  Lungs are clear to auscultation anteriorly.  No wheezes.  Cardiac exam:  S1, S2, regular rate.  No significant murmurs.  PMI is nondisplaced.  Abdomen:  Soft, nondistended.  Extremities:  Without edema, on limited exam.  Neurological exam seems to show only the right facial droop.,DIAGNOSTIC/LABORATORY DATA: , EKGs as reviewed above.  Her last ECG shows normalization of prior ST elevation in the inferior leads with Q waves and first-degree AV block, PR interval 280 milliseconds.  Further lab shows sodium 135, potassium 4.2, chloride 98, bicarbonate 26, BUN 9, creatinine 0.8, glucose 162, troponin 0.17, INR 1.27, white blood cell count 1.3, hematocrit 31, platelet count of 179.,Chest x-ray, no significant pericardial effusion.,IMPRESSION: , The patient is a 69-year-old woman with metastatic non-small-cell lung cancer with a recent hemorrhagic pericardial effusion, now admitted with cerebrovascular accident and transient inferior myocardial infarction, which appears to be canalized.  I will discuss this in detail with the patient and her daughter, and clearly, her situation is quite guarded with likely poor prognosis, which they are understanding of.,RECOMMENDATIONS:,1.  I think it is reasonable to continue heparin, but clearly she would be at risk for hemorrhagic pericardial effusion recurrence.,2.  Morphine is appropriate, especially for preload reduction and other comfort measures as appropriate.,3.  Would avoid other blood thinners including Plavix, Integrilin, and certainly, she is not a candidate for a thrombolytic with which the patient and her daughter are in agreement with after a long discussion.,Other management as per the medical service.  I have discussed the case with Dr. X of the hospitalist service who will be admitting the patient.
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DESCRIPTION: Patient with metastatic non-small-cell lung cancer, on hospice with inferior ST-elevation MI.  The patient from prior strokes has expressive aphasia, is not able to express herself in a clear meaningful fashion.

This situation involves a patient with a significant medical history including metastatic non-small-cell lung cancer, recent hemorrhagic pericardial effusion, and now an inferior ST-elevation myocardial infarction while on hospice care. The patient is also experiencing expressive aphasia from prior strokes, complicating communication. The presence of metastatic cancer and recent cardiac events requiring careful management of medications and interventions indicates the situation's complexity and potential impact on the patient's quality of life and prognosis. The medical team's decisions, including the avoidance of certain treatments due to high risks, highlight the high-stakes nature of providing end-of-life care in this context.