Medical Specialty: General Medicine
Sample Name: Gen Med SOAP - 9

SUBJECTIVE:  ,This patient presents to the office today for a checkup.  He has several things to go over and discuss.  First he is sick.  He has been sick for a month intermittently, but over the last couple of weeks it is worse.  He is having a lot of yellow phlegm when he coughs.  It feels likes it is in his chest.  He has been taking Allegra-D intermittently, but he is almost out and he needs a refill.  The second problem, his foot continues to breakout.  It seems like it was getting a lot better and now it is bad again.  He was diagnosed with tinea pedis previously, but he is about out of the Nizoral cream.  I see that he is starting to breakout again now that the weather is warmer and I think that is probably not a coincidence.  He works in the flint and it is really hot where he works and it has been quite humid lately.  The third problem is that he has a wart or a spot that he thinks is a wart on the right middle finger.  He is interested in getting that frozen today.  Apparently, he tells me I froze a previous wart on him in the past and it went away.  Next, he is interested in getting some blood test done.  He specifically mentions the blood test for his prostate, which I informed him is called the PSA.  He is 50 years old now.  He will also be getting his cholesterol checked again because he has a history of high cholesterol.  He made a big difference in his cholesterol by quitting smoking, but unfortunately after taking his social history today he tells me that he is back to smoking.  He says it is difficult to quit.  He tells me he did quit chewing tobacco.  I told him to keep trying to quit smoking.  ,REVIEW OF SYSTEMS:,  General:  With this illness he has had no problems with fever.  HEENT:  Some runny nose, more runny nose than congestion.  Respiratory:  Denies shortness of breath.  Skin:  He has a peeling skin on the bottom of his feet, mostly the right foot that he is talking about today.  At times it is itchy.,OBJECTIVE: , His weight is 238.4 pounds, blood pressure 128/74, temperature 97.8, pulse 80, and respirations 16.  General exam:  The patient is nontoxic and in no acute distress.  Ears:  Tympanic membranes pearly gray bilaterally.  Mouth:  No erythema, ulcers, vesicles, or exudate noted.  Neck is supple.  No lymphadenopathy.  Lungs:  Clear to auscultation.  No rales, rhonchi, or wheezing.  Cardiac:  Regular rate and rhythm without murmur.  Extremities:  No edema, cyanosis, or clubbing.  Skin exam:  I checked out the bottom of his right foot.  He has peeling skin visible consistent with tinea pedis.  On the anterior aspect of the right third finger there is a small little raised up area that I believe represents a wart.  The size of this wart is approximately 3 mm in diameter.,ASSESSMENT:  ,1.  Upper respiratory tract infection, persistent.,2.  Tinea pedis.,3.  Wart on the finger.,4.  Hyperlipidemia.,5.  Tobacco abuse.,PLAN: , The patient is getting a refill on Allegra-D.  I am giving him a refill on the Nizoral 2% cream that he should use to the foot area twice a day.  I gave him instructions on how to keep the foot clean and dry because I think the reason we are dealing with this persistent problem is the fact that his feet are hot and sweaty a lot because of his work.  His wart has been present for some time now and he would like to get it frozen.  I offered him the liquid nitrogen treatment and he did agree to it.  I used liquid nitrogen after a verbal consent was obtained from the patient to freeze the wart.  He tolerated the procedure very well.  I froze it once and I allowed for a 3 mm freeze zone.  I gave him verbal wound care instructions after the procedure.  Lastly, when he is fasting I am going to send him to the lab with a slip, which I gave him today for a basic metabolic profile, CBC, fasting lipid profile, and a screening PSA test.  Lastly, for the upper respiratory tract infection, I am giving him amoxicillin 500 mg three times a day for 10 days.
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DESCRIPTION: Upper respiratory tract infection, persistent.  Tinea pedis.  Wart on the finger.  Hyperlipidemia.  Tobacco abuse.

general medicine, hyperlipidemia, allegra-d, upper respiratory tract infection, tinea pedis wart, tobacco abuse, blood test, runny nose, peeling skin, tinea pedis, abuse, infection, wart,

The patient's condition seems to be stable and manageable with standard medical interventions. The issues such as persistent upper respiratory tract infection, tinea pedis, and a wart on the finger are common and generally low-risk if properly managed. The hyperlipidemia and tobacco abuse are concerns but are being addressed through medication and encouragement to quit smoking. The patient is not in acute distress, and the vital signs are within normal limits. Therefore, while the patient has multiple health issues, none are life-threatening or urgent, making this situation relatively low-stakes.


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

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

MULTISYSTEM EXAM,CONSTITUTIONAL:  ,The vital signs showed that the patient was afebrile; blood pressure and heart rate were within normal limits.  The patient appeared alert.,EYES:  ,The conjunctiva was clear.  The pupil was equal and reactive.  There was no ptosis.  The irides appeared normal.,EARS, NOSE AND THROAT:  ,The ears and the nose appeared normal in appearance.  Hearing was grossly intact.  The oropharynx showed that the mucosa was moist.  There was no lesion that I could see in the palate, tongue. tonsil or posterior pharynx.,NECK:  ,The neck was supple.  The thyroid gland was not enlarged by palpation.,RESPIRATORY:  ,The patient's respiratory effort was normal.  Auscultation of the lung showed it to be clear with good air movement.,CARDIOVASCULAR:  ,Auscultation of the heart revealed S1 and S2 with regular rate with no murmur noted.  The extremities showed no edema.,GASTROINTESTINAL: , The abdomen was soft, nontender with no rebound, no guarding, no enlarged liver or spleen.  Bowel sounds were present.,GU: , The scrotal elements were normal.  The testes were without discrete mass.  The penis showed no lesion, no discharge.,LYMPHATIC:  ,There was no appreciated node that I could feel in the groin or neck area.,MUSCULOSKELETAL:  ,The head and neck by inspection showed no obvious deformity.  Again, the extremities showed no obvious deformity.  Range of motion appeared to be normal for the upper and lower extremities.,SKIN: , Inspection of the skin and subcutaneous tissues appeared to be normal.  The skin was pink, warm and dry to touch.,NEUROLOGIC:  ,Deep tendon reflexes were symmetrical at the patellar area.  Sensation was grossly intact by touch.,PSYCHIATRIC: , The patient was oriented to time, place and person.  The patient's judgment and insight appeared to be normal.
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DESCRIPTION: Sample/template for a normal male multisystem exam.

office notes, within normal limits, conjunctiva, eyes, ears, nose, throat, male, multisystem, heart, respiratory, auscultation, extremities, oropharynx, neck, tongue,

The situation being described is a template for a normal male multisystem exam. It is a routine check-up template and does not involve any urgent medical intervention or critical health issues. It serves as a guide for practitioners to assess the baseline health status of a patient. Since it involves no immediate risks or high-stakes decisions, it is considered low-stakes.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: General Medicine
Sample Name: Female Exam & ROS

GENERAL REVIEW OF SYSTEMS,General:  No fevers, chills, or sweats.  No weight loss or weight gain.,Cardiovascular:  No exertional chest pain, orthopnea, PND, or pedal edema.  No palpitations.,Neurologic:  No paresis, paresthesias, or syncope.,Eyes:  No double vision or blurred vision.,Ears:  No tinnitus or decreased auditory acuity.,ENT:  No allergy symptoms, such as rhinorrhea or sneezing.,GI:  No indigestion, heartburn, or diarrhea.  No blood in the stools or black stools.  No change in bowel habits.,GU:  No dysuria, hematuria, or pyuria.  No polyuria or nocturia.  Denies slow urinary stream.,Psych:  No symptoms of depression or anxiety.,Pulmonary:  No wheezing, cough, or sputum production.,Skin:  No skin lesions or nonhealing lesions.,Musculoskeletal:  No joint pain, bone pain, or back pain.  No erythema at the joints.,Endocrine:  No heat or cold intolerance.  No polydipsia.,Hematologic:  No easy bruising or easy bleeding.  No swollen lymph nodes.,PHYSICAL EXAM,Vitals:  Blood pressure today was *, heart rate *, respiratory rate *.,Ears:  TMs intact bilaterally.  Throat is clear without hyperemia.,Mouth:  Mucous membranes normal.  Tongue normal.,Neck:  Supple; carotids 2+ bilaterally without bruits; no lymphadenopathy or thyromegaly.,Chest:  Clear to auscultation; no dullness to percussion.,Heart:  Revealed a regular rhythm, normal S1 and S2.  No murmurs, clicks or gallops.,Abdomen:  Soft to palpation without guarding or rebound.  No masses or hepatosplenomegaly palpable.  Bowel sounds are normoactive.,Extremities:  Bilaterally symmetrical.  Peripheral pulses 2+ in all extremities.  No pedal edema.,Neurologic examination:  Essentially intact including cranial nerves II through XII intact bilaterally.  Deep tendon reflexes 2+ and symmetrical.,Breasts:  Bilaterally symmetrical without tenderness, masses.  No axillary tenderness or masses.,Pelvic examination:  Revealed normal external genitalia.  Pap smear obtained without difficulty.  Bimanual examination revealed no pelvic tenderness or masses.  No uterine enlargement.  Rectal examination revealed normal sphincter tone, no rectal masses.  Stool is Hemoccult negative.
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DESCRIPTION: Sample female exam and review of systems.

general medicine, female exam, extremities, hemoccult, musculoskeletal, neurologic examination, pelvic examination, back pain, bone pain, chills, cough, cranial nerves ii through xii, fevers, heart rate, joint pain, paresis, paresthesias, polydipsia, regular rhythm, weight gain, wheezing, examination revealed, pelvic, rectal, heartburn, symmetrical, tenderness, indigestion, masses,

The description provided is a routine medical examination and review of systems for a female patient in a general medicine context. The examination findings are normal, with no significant medical concerns or symptoms reported. Routine check-ups and screening exams are typically low-stakes situations unless there are unusual findings or symptoms suggestive of a serious condition. The context here is a professional medical setting, but the examination itself does not suggest any immediate or serious concerns needing urgent attention.


Medical Specialty: Neurosurgery
Sample Name: Brain Stimulator Electrode

PREOPERATIVE DIAGNOSIS: , Tremor, dystonic form.,POSTOPERATIVE DIAGNOSIS: , Tremor, dystonic form.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Less than 100 mL.,ANESTHESIA:,  MAC (monitored anesthesia care) with local anesthesia.,TITLE OF PROCEDURES:,1.  Left frontal craniotomy for placement of deep brain stimulator electrode.,2.  Right frontal craniotomy for placement of deep brain stimulator electrode.,3.  Microelectrode recording of deep brain structures.,4.  Stereotactic volumetric CT scan of head for target coordinate determination.,5.  Intraoperative programming and assessment of device.,INDICATIONS:  ,The patient is a 61-year-old woman with a history of dystonic tremor.  The movements have been refractory to aggressive medical measures, felt to be candidate for deep brain stimulation.  The procedure is discussed below.,I have discussed with the patient in great deal the risks, benefits, and alternatives.  She fully accepted and consented to the procedure.,PROCEDURE IN DETAIL:,  The patient was brought to the holding area and to the operating room in stable condition.  She was placed on the operating table in seated position.  Her head was shaved.  Scalp was prepped with Betadine and a Leksell frame was mounted after anesthetizing the pin sites with a 50:50 mixture of 0.5% Marcaine and 2% lidocaine in all planes.  IV antibiotics were administered as was the sedation.  She was then transported to the CT scan and stereotactic volumetric CT scan of the head was undertaken.  The images were then transported to the surgery planned work station where a 3-D reconstruction was performed and the target coordinates were then chosen.  Target coordinates chosen were 20 mm to the left of the AC-PC midpoint, 3 mm anterior to the AC-PC midpoint, and 4 mm below the AC-PC midpoint.  Each coordinate was then transported to the operating room as Leksell coordinates.,The patient was then placed on the operating table in a seated position once again.  Foley catheter was placed, and she was secured to the table using the Mayfield unit.  At this point then the patient's right frontal and left parietal bossings were cleaned, shaved, and sterilized using Betadine soap and paint in scrubbing fashion for 10 minutes.  Sterile drapes placed around the perimeter of the field.  This same scalp region was then anesthetized with same local anesthetic mixture.,A bifrontal incision was made as well as curvilinear incision was made over the parietal bossings.  Bur holes were created on either side of the midline just behind the coronal suture.  Hemostasis was controlled using bipolar and Bovie, and self-retaining retractors had been placed in the field.  Using the drill, then two small grooves were cut in the frontal bone with a 5-mm cutting burs and Stryker drill.  The bur holes were then curetted free, the dura cauterized, and then opened in a cruciate manner on both sides with a #11 blade.  The cortical surface was then nicked with a #11 blade on both sides as well.  The Leksell arc with right-sided coordinate was dialed in, was then secured to the frame.  Microelectrode drive was secured to the arc.  Microelectrode recording was then performed.  The signatures of the cells were recognized.  Microelectrode unit was removed.  Deep brain stimulating electrode holding unit was mounted.  The DBS electrode was then loaded into target and intraoperative programming and testing was performed.  Using the screener box and standard parameters, the patient experienced some relief of symptoms on her left side.  This electrode was secured in position using bur-hole ring and cap system.,Attention was then turned to the left side, where left-sided coordinates were dialed into the system.  The microelectrode unit was then remounted.  Microelectrode recording was then undertaken.  After multiple passes, the microelectrode unit was removed.  Deep brain stimulator electrode holding unit was mounted at the desired trajectory.  The DBS electrode was loaded into target, and intraoperative programming and testing was performed once again using the screener box.  Using standard parameters, the patient experienced similar results on her right side.  This electrode was secured using bur-hole ring and cap system.  The arc was then removed.  A subgaleal tunnel was created between the two incisions whereby distal aspect of the electrodes led through this tunnel.,We then closed the electrode, replaced subgaleally.  Copious amounts of Betadine irrigation were used.  Hemostasis was controlled using the bipolar only.  Closure was instituted using 3-0 Vicryl in a simple interrupted fashion for the fascial layer followed by skin closure with staples.  Sterile dressings were applied.  The Leksell arc was then removed.,She was rotated into the supine position and transported to the recovery room in stable and satisfactory condition.  All needle, sponge, cottonoid, and blade counts were correct x2 as verified by the nurses.
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DESCRIPTION: Frontal craniotomy for placement of deep brain stimulator electrode.  Microelectrode recording of deep brain structures. Intraoperative programming and assessment of device.

neurosurgery, dystonic, ac-pc, ct scan, dbs electrode, intraoperative programming, microelectrode, stereotactic, tremor, brain stimulator, craniotomy, device, dystonic tremor, electrode, frontal, screener box, target coordinate, volumetric, deep brain stimulator electrode, brain stimulator electrode, volumetric ct, stimulator, brain,

The situation outlined involves a neurosurgical procedure for the implantation of a deep brain stimulator in a patient with a dystonic tremor that is refractory to medical treatment. This type of procedure, while common in neurosurgery for movement disorders, is intrinsically high-stakes due to the complexity of brain surgery, the use of stereotactic techniques, and the need for precise placement of electrodes. Risks include potential neurological damage, bleeding, and infection, although these complications are minimized with meticulous technique. The procedure's success directly impacts the patient's quality of life by potentially alleviating tremors, making it significantly impactful. Given the nature of brain surgery, the stakes remain high despite the routine nature of these operations in specialized centers.


Medical Specialty: Surgery
Sample Name: BMT & Adenoidectomy

PREOPERATIVE DIAGNOSIS: , Chronic otitis media.,POSTOPERATIVE DIAGNOSIS: , Chronic otitis media.,PROCEDURE PERFORMED: , Bilateral myringotomy tubes and adenoidectomy.,INDICATIONS FOR PROCEDURE:,  The patient is an 8-year-old child with history of recurrent otitis media.  The patient has had previous tube placement.  Tubes have since plugged and are no more functioning.  The patient has had recent recurrent otitis media.  Risks and benefits in terms of bleeding, anesthesia, and tympanic membrane perforation were discussed with the mother.  Mother wished to proceed with the surgery.,PROCEDURE IN DETAIL: , The patient was brought to the room, placed supine.  The patient was given general endotracheal anesthesia.  Starting on the left ear, under microscopic visualization, the ear was cleaned of wax.  A Bobbin tube was found stuck to the tympanic membrane.  This was removed.  After removing the tube the patient was found to have microperforation through which serous fluid was draining.  A fresh myringotomy was made in the anterior inferior quadrant.  More serous fluid was aspirated from middle ear space.  The new Bobbin tube was easily placed.  Floxin drops were placed in the ear.  In the right ear again under microscopic visualization, the ear was cleaned, the tube was removed off tympanic membrane.  There was no perforation seen; however, there was some granulation tissue on the surface of tympanic membrane.  A fresh myringotomy incision was made in the anterior inferior quadrant.  More serous fluid was drained out of middle ear space.  The tube was easily placed and Floxin drops were placed in the ear.  This completes tube portion of the surgery.  The patient was then turned and placed in the Rose position.  Shoulder roll was placed for neck extension.  Using a small McIvor mouth gag mouth was held open.  Using a rubber catheter the soft palate was retracted.  Under mirror visualization, the nasopharynx was examined.  The patient was found to have minimal adenoidal tissue.  This was removed using a suction Bovie.  The patient was then awakened from anesthesia, extubated and brought to recovery room in stable condition.  There were no intraoperative complications.  Needle and sponge count correct.  Estimated blood loss none.
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DESCRIPTION: Bilateral myringotomy tubes and adenoidectomy.

surgery, chronic otitis media, bilateral myringotomy tubes, adenoidectomy, myringotomy tubes and adenoidectomy, middle ear space, bilateral myringotomy, bobbin tube, fresh myringotomy, serous fluid, otitis media, tympanic membrane, tubes, myringotomy, otitis, media, membrane,

The procedure described is a standard surgical intervention for an 8-year-old child experiencing recurrent otitis media. This type of surgery, involving the insertion of bilateral myringotomy tubes and adenoidectomy, is common and generally considered low-risk. The description provided indicates that the procedure was without complications, and no significant blood loss occurred. Although any surgical procedure involving anesthesia carries some inherent risks, in this case, these risks were discussed with the patient's mother, and she consented to the surgery. The context suggests a level of routine and expectation of success typical in such procedures, making the stakes not particularly high compared to more complex or emergency surgeries.


Medical Specialty: Radiology
Sample Name: CT Brain: Subdural Hemorrhage.

CC: ,Difficulty with speech.,HX:, This 84 y/o RHF presented with sudden onset word finding and word phonation difficulties. She had an episode of transient aphasia in 2/92 during which she had difficulty with writing, written and verbal comprehension, and exhibited numerous semantic and phonemic paraphasic errors of speech. These problems resolved within 24 hours of onset and she had no subsequent speech problems prior to this presentation. Workup at that time revealed a right to left shunt on trans-thoracic echocardiogram. Carotid doppler studies showed 0-15% BICA stenosis and a LICA aneurysm (mentioned above). Brain CT was unremarkable. She was placed on ASA after the 2/92 event.,In 5/92 she was involved in a motor vehicle accident and suffered a fractured left humerus and left occipital scalp laceration. HCT at that time showed a small area of slightly increased attenuation at the posterior right claustrum only. This was not felt to be a contusion; nevertheless, she was placed on Dilantin seizure prophylaxis. Her left arm was casted and she returned home.,5 hours prior to presentation today, the patient began having difficulty finding words and putting them into speech. She was able to comprehend speech. This continued for an hour; then partially resolved for one hour; then returned; then waxed and waned. There was no reported weakness, numbness, incontinence, seizure-like activity, incoordination, HA, nausea, vomiting, or lightheadedness,MEDS:, ASA , DPH, Tenormin, Premarin, HCTZ,PMH:, 1)transient fluent aphasia 2/92 (which resolved), 2)bilateral carotid endarterectomies 1986, 3)HTN, 4)distal left internal carotid artery aneurysm.,EXAM:,  BP 168/70, Pulse 82, RR 16, 35.8F,MS:A & O x 3, Difficulty following commands, Speech fluent, and without dysarthria. There were occasional phonemic paraphasic errors.,CN: Unremarkable.,Motor: 5/5 throughout except for 4+ right wrist extension and right knee flexion.,Sensory: unremarkable.,Coordination: mild left finger-nose-finger dysynergia and dysmetria.,Gait: mildly unsteady tandem walk.,Station: no Romberg sign.,Reflexes: slightly more brisk at the left patella than on the right. Plantar responses were flexor bilaterally.,The remainder of the neurologic exam and the general physical exam were unremarkable.,LABS:, CBC WNL, Gen Screen WNL, , PT/PTT WNL, DPH 26.2mcg/ml, CXR WNL, EKG: LBBB, HCT revealed a left subdural hematoma.,COURSE:, Patient was taken to surgery and the subdural hematoma was evacuated. Her mental status, language skills, improved dramatically. The DPH dosage was adjusted appropriately.
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DESCRIPTION: HCT: Subdural hemorrhage.

HCT: Subdural hemorrhage.

radiology, ct brain, ct, difficulty with speech, hct, subdural hemorrhage, hemorrhage, phonation difficulties, subdural, transient fluent aphasia, phonemic paraphasic errors, hematoma, carotid, speech,

The situation involves an elderly patient who presented with neurological symptoms and was found to have a subdural hematoma, a potentially life-threatening condition. The timely diagnosis via CT scan and the subsequent surgical intervention are critical to prevent serious, potentially permanent neurological damage or death. The stakes are high due to the need for quick decision-making and surgical intervention to relieve the pressure caused by the hemorrhage.


Medical Specialty: Radiology
Sample Name: CT Head - 3

REASON FOR EXAM:  ,Left arm and hand numbness.,TECHNIQUE: , Noncontrast axial CT images of the head were obtained with 5 mm slice thickness.,FINDINGS:  ,There is an approximately 5-mm shift of the midline towards the right side.  Significant low attenuation is seen throughout the white matter of the right frontal, parietal, and temporal lobes.  There is loss of the cortical sulci on the right side.  These findings are compatible with edema.  Within the right parietal lobe, a 1.8 cm, rounded, hyperintense mass is seen.,No hydrocephalus is evident.,The calvarium is intact.  The visualized paranasal sinuses are clear.,IMPRESSION:  ,A 5 mm midline shift to the left side secondary to severe edema of the white matter of the right frontal, parietal, and temporal lobes.  A 1.8 cm high attenuation mass in the right parietal lobe is concerning for hemorrhage given its high density.  A postcontrast MRI is required for further characterization of this mass.  Gradient echo imaging should be obtained.
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DESCRIPTION: Left arm and hand numbness.  CT head without contrast.  Noncontrast axial CT images of the head were obtained with 5 mm slice thickness.

radiology, numbness, head, ct images, frontal, parietal, temporal, axial ct images, parietal and temporal, ct head, slice thickness, white matter, frontal parietal, temporal lobes, parietal lobe, edema, intact, noncontrast, mass, ct, lobes, arm,

The CT findings indicate severe edema and a significant mass in the brain, with a midline shift, suggesting potential serious neurological implications such as brain hemorrhage or tumor. These findings could have urgent medical consequences and require immediate attention and further testing like an MRI. Therefore, these findings represent a high-stakes situation as they could significantly impact patient health outcomes.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Low-Transverse C-Section & BTL - 1

PREOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy at 30 and 4/7th weeks.,2.  Previous cesarean section x2.,3.  Multiparity.,4.  Request for permanent sterilization.,POSTOPERATIVE DIAGNOSIS:,1.  Intrauterine pregnancy at 30 and 4/7th weeks.,2.  Previous cesarean section x2.,3.  Multiparity.,4.  Request for permanent sterilization.,5.  Breach presentation in the delivery of a liveborn female neonate.,PROCEDURES PERFORMED:,1.  Repeat low transverse cesarean section.,2.  Bilateral tubal ligation (BTL).,TUBES: , None.,DRAINS: , Foley to gravity.,ESTIMATED BLOOD LOSS: , 600 cc.,FLUIDS:,  200 cc of crystalloids.,URINE OUTPUT:,  300 cc of clear urine at the end of the procedure.,FINDINGS:,  Operative findings demonstrated a wire mesh through the anterior abdominal wall and the anterior fascia.  There were bowel adhesions noted through the anterior abdominal wall.  The uterus was noted to be within normal limits.  The tubes and ovaries bilaterally were noted to be within normal limits.  The baby was delivered from the right sacral anterior position without any difficulty.  Apgars 8 and 9.  Weight was 7.5 lb.,INDICATIONS FOR THIS PROCEDURE:  ,The patient is a 23-year-old G3 P 2-0-0-2 with reported 30 and 4/7th weeks' for a scheduled cesarean section secondary to repeat x2.  She had her first C-section because of congenial hip problems.  In her second C-section, baby was breached, therefore, she is scheduled for a third C-section.  The patient also requests sterilization.  Therefore, she requested a tubal ligation.,PROCEDURE: , After informed consent was obtained and all questions were answered to the patient's satisfaction in layman's terms, she was taken to the operating room where a spinal with Astramorph anesthesia was obtained without any difficulty.  She was placed in the dorsal supine position with a leftward tilt and prepped and draped in the usual sterile fashion.  A Pfannenstiel skin incision was made removing the old scar with a first knife and then carried down to the underlying layer of fascia with a second knife.  The fascia was excised in the midline extended laterally with the Mayo scissors.  The superior aspect of the fascial incision was then tented up with Ochsner clamps and the underlying rectus muscle dissected off sharply with the Metzenbaum scissors.  There was noted dense adhesions at this point as well as a wire mesh was noted.  The anterior aspect of the fascial incision was then tented up with Ochsner clamps and the underlying rectus muscle dissected off sharply as well as bluntly.  The rectus muscle superiorly was opened with a hemostat.  The peritoneum was identified and entered bluntly digitally.  The peritoneal incision was then extended superiorly up to the level of the mesh.  Then, inferiorly using the knife, the adhesions were taken down and the bladder was identified and the peritoneum incision extended inferiorly to the level of the bladder.  The bladder blade was inserted and vesicouterine peritoneum was identified and tented up with Allis clamps and bladder flap was created sharply with the Metzenbaum scissors digitally.  The bladder blade was then reinserted to protect the bladder and the uterine incision was made with a first knife and then extended laterally with the Bandage scissors.  The amniotic fluid was noted to be clear.  At this point, upon examining the intrauterine contents, the baby was noted to be breached.  The right foot was identified and then the baby was delivered from the double footling breach position without any difficulty.  The cord was clamped and the baby was then handed off to awaiting pediatricians.  The placenta cord gases were obtained and the placenta was then manually extracted from the uterus.  The uterus was exteriorized and cleared of all clots and debris.  Then, the uterine incision was then closed with #0 Vicryl in a double closure stitch fashion, first layer in locking stitch fashion and the second layer an imbricating layer.  Attention at this time was turned to the tubes bilaterally.,Both tubes were isolated and followed all the way to the fimbriated end and tented up with the Babcock clamp.  The hemostat was probed through the mesosalpinx in the avascular area and then a section of tube was clamped off with two hemostats and then transected with the Metzenbaum scissors.  The ends was then burned with the cautery and then using a #2-0 Vicryl suture tied down.  Both tube sections were noted to be hemostatic and the tubes were then sent to pathology for review.  The uterus was then replaced back into the abdomen.  The gutters were cleared of all clots and debris.  The uterine incision was then once again inspected and noted to be hemostatic.  The bladder flap was then replaced back into the uterus with #3-0 interrupted sutures.  The peritoneum was then closed with #3-0 Vicryl in a running fashion.  Then, the area at the fascia where the mesh had been cut and approximately 0.5 cm portion was repaired with #3-0 Vicryl in a simple stitch fashion.  The fascia was then closed with #0 Vicryl in a running fashion.  The subcutaneous layer and Scarpa's fascia were repaired with a #3-0 Vicryl.  Then, the skin edges were reapproximated using sterile clips.  The dressing was placed.  The uterus was then cleared of all clots and debris manually.  Then, the patient tolerated the procedure well.  Sponge, lap, and needle, counts were correct x2.  The patient was taken to recovery in sable condition.  She will be followed up throughout her hospital stay.
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DESCRIPTION: Repeat low transverse cesarean section and bilateral tubal ligation (BTL).   Intrauterine pregnancy at 30 and 4/7th weeks, previous cesarean section x2, multiparity, request for permanent sterilization, and breach presentation in the delivery of a liveborn female neonate.

The situation involves a complex surgical procedure, a repeat cesarean section with bilateral tubal ligation, to address both an intrauterine pregnancy and a request for permanent sterilization, all occurring at preterm gestation of 30 and 4/7 weeks. The stakes are high due to multiple factors: the surgery occurs at an early gestational age, involves surgical risks associated with a C-section and sterilization, previous surgeries (with two prior C-sections), and the necessity to manage a breach presentation in the delivery. Moreover, there is a history of surgical complications (adhesions, mesh), increasing the procedure's complexity. The likelihood of surgical complications such as excessive bleeding, infection, and challenges associated with the surgical history (e.g., wire mesh, adhesions) presents potential high-stakes implications for the mother and the neonate's health. Successful outcomes can impact both the immediate and long-term health of both mother and child.


Medical Specialty: Surgery
Sample Name: Myringotomy/Tube Insertion - 1

PREOPERATIVE DIAGNOSIS: , Bilateral chronic serous otitis media.,POSTOPERATIVE DIAGNOSIS: , Bilateral chronic serous otitis media.,OPERATION PERFORMED:,1.  Bilateral myringotomies.,2.  Insertion of Shepard grommet draining tubes.,ANESTHESIA: , General, by mask.,ESTIMATED BLOOD LOSS: , Less than 1 mL.,COMPLICATIONS:,  None.,FINDINGS:  ,The patient had a long history of persistent recurrent infections and was placed on antibiotics for the same.  At this point in time, he had a small amount of thick mucoid material in both middle ear spaces with middle ear mucosa somewhat inflamed, but no active acute infection at this point in time.,PROCEDURE:,  With the patient under adequate general anesthesia with the mask delivery of anesthesia, he had his ear canals cleaned utilizing an operating microscope and all foul cerumen had been removed from both sides.  Bilateral inferior radial myringotomies were performed, first on the right and then on the left.  Middle ear spaces were suctioned of small amount of thick mucoid material on both sides and then Shepard grommet draining tubes were inserted on either side.  Floxin drops were then instilled bilaterally to decrease any clotting within the tubes, and then cotton ball was placed in the external meatus bilaterally.  At this point, the patient was awakened and returned to the recovery room, satisfactory, with no difficulty encountered.
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DESCRIPTION: Bilateral myringotomies and insertion of Shepard grommet draining tubes.

surgery, serous otitis media, floxin drops, shepard grommet, cerumen, cotton ball, middle ear, mucoid, myringotomies, tubes, shepard grommet draining tubes, serous otitis, shepard, grommet, insertion

The situation describes a surgical procedure for chronic otitis media which is a relatively common issue and not considered highly risky. The procedure, myringotomy with tube insertion, is routine and performed under general anesthesia, with minimal blood loss and no complications reported. This indicates a low-stakes scenario typical for such procedures. Given these factors, the stakes are relatively low for this surgical intervention compared to more complex or risky surgeries.


Medical Specialty: Surgery
Sample Name: Spermatocelectomy, Epididymectomy, & Vasectomy

PREOPERATIVE DIAGNOSES:,1.  Left spermatocele.,2.  Family planning.,POSTOPERATIVE DIAGNOSES:,1.  Left spermatocele.,2.  Family planning.,PROCEDURE PERFORMED:,1.  Left spermatocelectomy/epididymectomy.,2.  Bilateral partial vasectomy.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS:,  Minimal.,SPECIMEN: , Left-sided spermatocele, epididymis, and bilateral partial vasectomy.,DISPOSITION:  ,To PACU in stable condition.,INDICATIONS AND FINDINGS: , This is a 48-year-old male with a history of a large left-sided spermatocele with significant discomfort.  The patient also has family status complete and desired infertility.  The patient was scheduled for elective left spermatocelectomy and bilateral partial vasectomy.,FINDINGS: , At this time of the surgery, significant left-sided spermatocele was noted encompassing almost the entirety of the left epididymis with only minimal amount of normal appearing epididymis remaining.,DESCRIPTION OF PROCEDURE:,  After informed consent was obtained, the patient was moved to the operating room.  A general anesthesia was induced by the Department of Anesthesia.,The patient was prepped and draped in the normal sterile fashion for a scrotal approach.  A #15 blade was used to make a transverse incision on the left hemiscrotum.  Electrocautery was used to carry the incision down into the tunica vaginalis and the testicle was delivered into the field.  The left testicle was examined.  A large spermatocele was noted.  Metzenbaum scissors were used to dissect the tissue around the left spermatocele.  Once the spermatocele was identified, as stated above, significant size was noted encompassing the entire left epididymis.  Metzenbaum scissors as well as electrocautery was used to dissect free the spermatocele from its testicular attachments and spermatocelectomy and left epididymectomy was completed with electrocautery.  Electrocautery was used to confirm excellent hemostasis.  Attention was then turned to the more proximal aspect of the cord.  The vas deferens was palpated and dissected free with Metzenbaum scissors.  Hemostats were placed on the two aspects of the cord, approximately 1 cm segment of cord was removed with Metzenbaum scissors and electrocautery was used to cauterize the lumen of the both ends of vas deferens and silk ties used to ligate the cut ends.  Testicle was placed back in the scrotum in appropriate anatomic position.  The dartos tissue was closed with running #3-0 Vicryl and the skin was closed in a horizontal interrupted mattress fashion with #4-0 chromic.  Attention was then turned to the right side.  The vas was palpated in the scrotum.  A small skin incision was made with a #15 blade and the vas was grasped with a small Allis clamp and brought into the surgical field.  A scalpel was used to excise the vas sheath and vas was freed from its attachments and grasped again with a hemostat.  Two ends were hemostated with hemostats and divided with Metzenbaum scissors.  Lumen was coagulated with electrocautery.  Silk ties used to ligate both cut ends of the vas deferens and placed back into the scrotum.  A #4-0 chromic suture was used in simple fashion to reapproximate the skin incision.  Scrotum was cleaned and bacitracin ointment, sterile dressing, fluffs, and supportive briefs applied.  The patient was sent to Recovery in stable condition.  He was given prescriptions for doxycycline 100 mg b.i.d., for five days and Vicodin ES 1 p.o. q.4h. p.r.n., pain, #30 for pain.  The patient is to followup with Dr. X in seven days.
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DESCRIPTION: Left spermatocelectomy/epididymectomy and bilateral partial vasectomy.  Left spermatocele and family planning.

surgery, partial vasectomy, spermatocele, epididymis, family planning, vas deferens, metzenbaum scissors, vasectomy, spermatocelectomy, epididymectomy, testicle, deferens, hemostats, electrocautery,

The surgical procedures described are relatively routine and elective rather than emergency or life-saving. A spermatocelectomy addresses a benign condition causing discomfort, and the vasectomy is for family planning, indicating a planned and considered decision by the patient. While surgery always involves inherent risks, such as complications from anesthesia or infection, these procedures do not typically impact the patient's immediate health or life expectancy. Thus, it is not classified as high-stakes compared to emergency or critical surgeries.


Medical Specialty: Gastroenterology
Sample Name: Barium Enema

EXAM: , Barium enema.,CLINICAL HISTORY: , A 4-year-old male with a history of encopresis and constipation.,TECHNIQUE:  ,A single frontal scout radiograph of the abdomen was performed.  A rectal tube was inserted in usual sterile fashion, and retrograde instillation of barium contrast was followed via spot fluoroscopic images.  A post-evacuation overhead radiograph of the abdomen was performed.,FINDINGS:,  The scout radiograph demonstrates a nonobstructive gastrointestinal pattern.  There are no suspicious calcifications seen or evidence of gross free intraperitoneal air.  The visualized lung bases and osseous structures are within normal limits.,The rectum and colon is of normal caliber throughout its course.  There is no evidence of obstruction, as contrast is seen to flow without difficulty into the right colon and cecum.  A small amount of contrast is seen to opacify small bowel loops on the post-evacuation image.  There is also opacification of a normal-appearing appendix documented.,IMPRESSION: , Normal barium enema.
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DESCRIPTION: Barium enema - history of encopresis and constipation.

gastroenterology, encopresis and constipation, scout radiograph, post evacuation, barium enema, encopresis, constipation, evacuation, colon, radiograph, contrast, enema, barium,

The medical procedure described is a diagnostic imaging test involving a barium enema for a 4-year-old patient with encopresis and constipation. The findings indicate a normal barium enema without any obstruction or abnormality. Given that the findings are normal and there is no immediate life-threatening condition or need for surgical intervention, this situation is not high-stakes. It is part of routine diagnostic procedures to assess gastrointestinal conditions in young patients. The interpretation of normal findings reduces the risk and urgency associated with the case. Therefore, while appropriately important to the health of the child, the situation lacks elements that would increase its stakes significantly.


Medical Specialty: Orthopedic
Sample Name: Arthrotomy & I&D

PREOPERATIVE DIAGNOSIS: , Hemarthrosis, left knee, status post total knee replacement, rule out infection.,POSTOPERATIVE DIAGNOSIS: , Hemarthrosis, left knee, status post total knee replacement, rule out infection.,OPERATIONS:,1.  Arthrotomy, left total knee.,2.  Irrigation and debridement, left knee.,3.  Polyethylene exchange, left knee.,COMPLICATION: , None.,TOURNIQUET TIME:  ,58 minutes.,ESTIMATED BLOOD LOSS: , Minimal.,ANESTHESIA:  ,General.,INDICATIONS:  ,This patient underwent an uncomplicated left total knee replacement.  Postoperatively, unfortunately did not follow up with PT/INR blood test and he was taking Coumadin.  His INR was seemed to elevated and developed hemarthrosis.  Initially, it did look very benign, although over the last 24 hours it did become irritable and inflamed, and he therefore was indicated with the above-noted procedure.,This procedure as well as alternatives was discussed in length with the patient and he understood them well.  Risks and benefits were also discussed.  Risks such as bleeding, infection, damage to blood vessels, damage to nerve roots, need for further surgeries, chronic pain with range of motion, risk of continued discomfort, risk of need for further reconstructive procedures, risk of need for total knee revision, risk of blood clots, pulmonary embolism, myocardial infarction, and risk of death were discussed.  He understood them well.  All questions were answered and he signed consent for the procedure as described.,DESCRIPTION OF PROCEDURE: , The patient was placed on operating table and general anesthesia was achieved.  The left lower extremity was then prepped and draped in the usual sterile manner.  The leg was elevated and the tourniquet was inflated to 325 mmHg.  A longitudinal incision was then made and carried down through subcutaneous tissues.  This was made through the prior incision site.  There were some fatty necrotic tissues through the incision region and all necrotic tissue was debrided sharply on both sides of the incision site.  Medial and lateral flaps were then made.  The prior suture was identified, the suture removed and then a medial parapatellar arthrotomy was then performed.  Effusion within the knee was noted.  All hematoma was evacuated.  I then did flex the knee and removed the polyethylene.  Once the polyethylene was removed I did irrigate the knee with total of 9 liters of antibiotic solution.  Further debridement was performed of all inflamed tissue and thickened synovial tissue.  A 6 x 16-mm Stryker polyethylene was then snapped back in position.  The knee has excellent stability in all planes and I did perform a light manipulation to improve the flexion of the knee.  Further irrigation was performed on the all soft tissue in the knee with additional 3 liters of normal saline.  The knee was placed in a flexed position and the extensor mechanism was reapproximated using #2 Ethibond suture in a figure-of-eight manner.  The subcutaneous tissue was reapproximated in layers using #1 and 2-0 Vicryl sutures, and the skin was reapproximated using staples.  Prior to closure a Hemovac drain was inserted through a superolateral approach into the knee joint.,No complications were encountered throughout the procedure, and the patient tolerated the procedure well.  The patient was taken to recovery room in stable condition.
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DESCRIPTION: Hemarthrosis, left knee, status post total knee replacement, rule out infection.  Arthrotomy, irrigation and debridement, and polyethylene exchange, left knee.  No complications were encountered throughout the procedure.

The procedure described is a follow-up surgery after a total knee replacement due to complications involving hemarthrosis, with the possibility of infection. Although successfully performed without complications, the stakes are high due to the potential severity of post-surgical risks discussed, including infection, further surgeries, or even life-threatening conditions like pulmonary embolism. Additionally, it involves general anesthesia and significant physical intervention on a replaced knee joint, which inherently carry high stakes.


Medical Specialty: Gastroenterology
Sample Name: Colonoscopy - 2

PREOPERATIVE DIAGNOSES:,  Prior history of anemia, abdominal bloating.,POSTOPERATIVE DIAGNOSIS:,  External hemorrhoids, otherwise unremarkable colonoscopy.,PREMEDICATIONS:,  Versed 5 mg, Demerol 50 mg IV.,REPORT OF PROCEDURE:,  Digital rectal exam revealed external hemorrhoids.  The colonoscope was inserted into the rectal ampulla and advanced to the cecum.  The position of the scope within the cecum was verified by identification of the appendiceal orifice.  The cecum, the ascending colon, hepatic flexure, transverse colon, splenic flexure, descending colon, and rectum were normal.  The scope was retroflexed in the rectum and no abnormality was seen.  So the scope was straightened, withdrawn, and the procedure terminated.,ENDOSCOPIC IMPRESSION:,1.  Normal colonoscopy.,2.  External hemorrhoids.
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DESCRIPTION: Colonoscopy in a patient with prior history of anemia and abdominal bloating.

gastroenterology, colonoscopy, digital rectal exam, abdominal, anemia, ascending colon, bloating, cecum, colonoscope, descending colon, hemorrhoids, hepatic flexure, rectal ampulla, rectum, splenic flexure, transverse colon, external hemorrhoids, scope,

The situation involves a colonoscopy to investigate issues such as anemia and abdominal bloating, resulting in a diagnosis of external hemorrhoids and otherwise normal findings. While this medical procedure can be important for diagnosing or ruling out more serious conditions, the overall findings were positive and showed no serious abnormalities besides external hemorrhoids. Given these results, the stakes are not as high as if there had been significant discoveries like polyps or signs of cancerous growths.


Medical Specialty: Surgery
Sample Name: YAG Laser Capsulotomy

PREOPERATIVE DIAGNOSIS:,  Visually significant posterior capsule opacity, right eye.,POSTOPERATIVE DIAGNOSIS:,  Visually significant posterior capsule opacity, right eye.,OPERATIVE PROCEDURES:  ,YAG laser posterior capsulotomy, right eye.,ANESTHESIA: , Topical anesthesia using tetracaine ophthalmic drops.,INDICATIONS FOR SURGERY: , This patient was found to have a visually significant posterior capsule opacity in the right eye.  The patient has had a mild decrease in visual acuity, which has been a gradual change.  The posterior capsule opacity was felt to be related to the decline in vision.  The risks, benefits, and alternatives (including observation) were discussed.  I feel the patient had a good understanding of the proposed procedure and informed consent was obtained.,DESCRIPTION OF PROCEDURE: , The patient was identified and the procedure was verified.  Pupil was dilated per protocol.  Patient was positioned at the YAG laser.  Then, *** of energy were used to perform a circular posterior laser capsulotomy through the visual axis.  A total of ** shots were used.  Total energy was **.  The patient tolerated the procedure well and there were no complications.  The lens remained well centered and stable.  Postoperative instructions were provided.  Alphagan P ophthalmic drops times two were instilled prior to his dismissal.,Post-laser intraocular pressure measured ** mmHg.  Postoperative instructions were provided and the patient had no further questions.
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DESCRIPTION: Visually significant posterior capsule opacity, right eye.  YAG laser posterior capsulotomy, right eye.

surgery, capsule opacity, yag, ophthalmic, yag laser posterior capsulotomy, capsulotomy, opacity, laser, visually, eye, anesthesia

The procedure described is a YAG laser capsulotomy, a common and generally low-risk outpatient procedure performed to treat posterior capsule opacity, which can occur after cataract surgery. While all surgical procedures carry some inherent risks, this type of surgery is routine, minimally invasive, and typically has a high success rate with few complications. The situation involves ensuring the patient's vision is corrected, but it does not typically pose a significant risk to the patient's life or overall health beyond the impact on vision. Therefore, it is not considered a high-stakes medical situation.


Medical Specialty: Nephrology
Sample Name: Shockwave Lithotripsy

PREOPERATIVE DIAGNOSIS:,  Right renal stone.,POSTOPERATIVE DIAGNOSIS:  ,Right renal stone.,PROCEDURE: , Right shockwave lithotripsy, cystoscopy, and stent removal x2.,ANESTHESIA: , LMA.,ESTIMATED BLOOD LOSS:,  Minimal.  The patient was given antibiotics preoperatively.,HISTORY: , This is a 47-year-old male who presented with right renal stone and right UPJ stone.  The right UPJ stone was removed using ureteroscopy and laser lithotripsy and the stone in the kidney.  The plan was for shockwave lithotripsy.  The patient had duplicated system on the right side.  Risk of anesthesia, bleeding, infection, pain, MI, DVT, PE was discussed.  Options such as watchful waiting, passing the stone on its own, and shockwave lithotripsy were discussed.  The patient wanted to proceed with the shockwave to break the stone into small pieces as possible to allow the stones to pass easily.  Consent was obtained.,DETAILS OF THE OPERATION:  ,The patient was brought to the OR.  Anesthesia was applied.  The patient was placed in the supine position.  Using Dornier lithotriptor total of 2500 shocks were applied.  Energy levels were slowly started at O2 increased up to 7; gradually the stone seem to have broken into smaller pieces as the number of shocks went up.  The shocks were started at 60 per minute and slowly increased up to 90 per minute.  The patient's heart rate and blood pressure were stable throughout the entire procedure.,After the end of the shockwave lithotripsy the patient was placed in dorsal lithotomy position.  The patient was prepped and draped in usual sterile fashion and cystoscopy was done.  Using graspers, the stent was grasped x2 and pulled out, both stents were removed.  The patient tolerated the procedure well.  The patient was brought to recovery in stable condition.  The plan was for the patient to follow up with us and plan for KUB in about two to three months.
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DESCRIPTION: Right shockwave lithotripsy, cystoscopy, and stent removal x2.

nephrology, renal stone, stent removal, upj stone, shockwave lithotripsy, cystoscopy, stent, renal, shocks, upj, shockwave, lithotripsy, stone

Shockwave lithotripsy is a common and generally low-risk procedure used to break down kidney stones non-invasively using shock waves. The procedure described appears to have gone smoothly with the patient remaining stable throughout. While any medical procedure carries some risk, the stakes here are relatively low because it is a routine procedure with low complication rates, and the patient's vital signs remained stable. Post-operative monitoring and follow-ups are usual protocol. The reference to risks and alternatives suggests that the patient was well-informed and consented to the procedure after considering other options. Overall, the situation doesn't involve immediate life-threatening conditions or major surgical interventions.


Medical Specialty: Urology
Sample Name: Cystoprostatectomy

PREOPERATIVE DIAGNOSES:,1.  Clinical stage T2, NX, MX transitional cell carcinoma of the urinary bladder, status post chemotherapy and radiation therapy.,2.  New right hydronephrosis.,POSTOPERATIVE DIAGNOSES:,1.  Clinical stage T4a, N3, M1 transitional cell carcinoma of the urinary bladder, status post chemotherapy and radiation therapy.,2.  New right hydronephrosis.,3.  Carcinoid tumor of the small bowel.,TITLE OF OPERATION: , Exploratory laparotomy, resection of small bowel lesion, biopsy of small bowel mesentery, bilateral extended pelvic and iliac lymphadenectomy (including preaortic and precaval, bilateral common iliac, presacral, bilateral external iliac lymph nodes), salvage radical cystoprostatectomy (very difficult due to previous chemotherapy and radiation therapy), and continent urinary diversion with an Indiana pouch.,ANESTHESIA: , General endotracheal and epidural.,INDICATIONS: , This patient is a 65-year-old white male, who was diagnosed with a high-grade invasive bladder cancer in June 2005.  During the course of his workup of transurethral resection, he had a heart attack when he was taken off Plavix after having had a drug-eluting stent placed in.  He recovered from this and then underwent chemotherapy and radiation therapy with a brief response documented by cystoscopy and biopsy after which he had another ischemic event.  The patient has been followed regularly by myself and Dr. X and has been continuously free of diseases since that time.  In that interval, he had a coronary artery bypass graft and was taken off of Plavix.  Most recently, he had a PET CT, which showed new right hydronephrosis and a followup cystoscopy, which showed a new abnormality in the right side of his bladder where he previously had the tumor resected and treated.  I took him to the operating room and extensively resected this area with findings of a high-grade muscle invasive bladder cancer.  We could not identify the right ureteral orifice, and he had a right ureteral stent placed.  Metastatic workup was negative and Cardiology felt he was at satisfactory medical risk for surgery and he was taken to the operating room this time for planned salvage cystoprostatectomy.  He was interested in orthotopic neobladder, and I felt like that would be reasonable if resecting around the urethra indicated the tissue was healthier.  Therefore, we planned on an Indiana pouch continent cutaneous diversion.,OPERATIVE FINDINGS:  ,On exploration, there were multiple abnormalities outside the bladder as follows:  There were at least three small lesions within the distal small bowel, the predominant one measured about 1.5 cm in diameter with a white scar on the surface.  There were two much smaller lesions also with a small white scar, with very little palpable mass.  The larger of the two was resected and found to be a carcinoid tumor.  There also were changes in the small bowel mesentry that looked inflammatory and biopsies of this showed only fibrous tissue and histiocytes.  The small bowel mesentry was fairly thickened at the base, but no discrete abnormality noted.,Both common iliac and lymph node samples were very thickened and indurated, and frozen section of the left showed cancer cells that were somewhat degenerative suggesting a chemotherapy and radiation therapy effect; viability was unable to be determined.  There was a frozen section of the distal right external iliac lymph node that was negative.  The bladder was very thickened and abnormal suggesting extensive cancer penetrating just under the peritoneal surface.  The bladder was fairly stuck to the pelvic sidewall and anterior symphysis pubis requiring very meticulous resection in order to get it off of these structures.  The external iliac lymph nodes were resected on both sides of the obturator; the lymph packet, however, was very stuck and adherent to the pelvic sidewall, and I elected not to remove that.  The rest of the large bowel appeared normal.  There were no masses in the liver, and the gallbladder was surgically absent.  There was nasogastric tube in the stomach.,OPERATIVE PROCEDURE IN DETAIL: , The patient was brought to the operative suite, and after adequate general endotracheal and epidural anesthesia obtained, having placed in the supine position and flexed over the anterior superior iliac spine, his abdomen and genitalia were sterilely prepped and draped in usual fashion.  The radiologist placed a radial arterial line and an intravenous catheter.  Intravenous antibiotics were given for prophylaxis.  We made a generous midline skin incision from high end of the epigastrium down to the symphysis pubis, deepened through the rectus fascia, and the rectus muscles separated in the midline.  Exploration was carried out with the findings described.  The bladder was adherent and did appear immobile.  Moist wound towels and a Bookwalter retractor was placed for exposure.  We began by assessing the small and large bowel with the findings in the small bowel as described.  We subsequently resected the largest of the lesions by exogenous wedge resection and reanastomosed the small bowel with a two-layer running 4-0 Prolene suture.  We then mobilized the cecum and ascending colon and hepatic flexure after incising the white line of Toldt and mobilized the terminal ileal mesentery up to the second and third portion of the duodenum.  The ureters were carefully dissected out and down deep in the true pelvis.  The right ureter was thickened and hydronephrotic with a stent in place and the left was of normal caliber.  I kept the ureters intact until we were moving the bladder off as described above.  At that point, we then ligated the ureters with the RP-45 vascular load and divided it.,We then established the proximal ____________ laterally to both genitofemoral nerves and resected the precaval and periaortic lymph nodes.  The common iliac lymph nodes remained stuck to the ureter.  Frozen section with the findings described on the left.,I then began the dissection over the right external iliac artery and vein and had a great deal of difficulty dissecting distally.  I was, however, able to establish the distal plane of dissection and a large lymph node was present in the distal external iliac vessels.  Clips were used to control the lymphatics distally.  These lymph nodes were sent for frozen section, which was negative.  We made no attempt to circumferentially mobilize the vessels, but essentially, swept the tissue off of the anterior surface and towards the bladder and then removed it.  The obturator nerve on the right side was sucked into the pelvic sidewall, and I elected not to remove those.  On the left side, things were a little bit more mobile in terms of the lymph nodes, but still the obturator lymph nodes were left intact.,We then worked on the lateral pedicles on both sides and essentially determined that I can take these down.  I then mobilized the later half of the symphysis pubis and pubic ramus to get distal to the apical prostate.  At this point, I scrubbed out of the operation, talked to the family, and indicated that I felt the cystectomy was more palliative than therapeutic, and I reiterated his desire to be free of any external appliance.,I then proceeded to take down the lateral pedicles with an RP-45 stapler on the right and clips distally.  The endopelvic fascia was incised.  I then turned my attention posteriorly and incised the peritoneum overlying the anterior rectal wall and ramus very meticulously dissected the rectum away from the posterior Denonvilliers fascia.  I intentionally picked down those two pedicles lateral to the rectum between the clips and then turned my attention retropubically.  I was able to pass a 0 Vicryl suture along the dorsal venous complex, tied this, and then, sealed and divided the complex with a LigaSure and oversewed it distally with 2-0 Vicryl figure-of-eight stitch.  I then divided the urethra distal to the apex of the prostate, divided the Foley catheter between the clamps and then the posterior urethra.  I then was able to take down the remaining distal attachments of the apex and took the dissection off the rectum, and the specimen was then free of all attachments and handed off the operative field.  The bivalved prostate appeared normal.  We then carefully inspected the rectal wall and noted to be intact.  The wound was irrigated with 1 L of warm sterile water and a meticulous inspection made for hemostasis and a dry pack placed in the pelvis.,We then turned our attention to forming the Indiana pouch.  I completed the dissection of the right hepatic flexure and the proximal transverse colon and mobilized the omentum off of this portion of the colon.  The colon was divided proximal to the middle colic using a GIA-80 stapler.  I then divided the avascular plane of Treves along the terminal ileum and selected a point approximately 15 cm proximal to the ileocecal valve to divide the ileum.  The mesentery was then sealed with a LigaSure device and divided, and the bowel was divided with a GIA-60 stapler.  We then performed a side-to-side ileo-transverse colostomy using a GIA-80 stapler, closing the open end with a TA 60.  The angles were reinforced with silk sutures and the mesenteric closed with interrupted silk sutures.,We then removed the staple line along the terminal ileum, passed a 12-French Robinson catheter into the cecal segment, and plicated the ileum with 3 firings of the GIA-60 stapler.  The ileocecal valve was then reinforced with interrupted 3-0 silk sutures as described by Rowland, et al, and following this, passage of an 18-French Robinson catheter was associated with the characteristic "pop," indicating that we had adequately plicated the ileocecal valve.,As the patient had had a previous appendectomy, we made an opening in the cecum in the area of the previous appendectomy.  We then removed the distal staple line along the transverse colon and aligned the cecal end and the distal middle colic end with two 3-0 Vicryl sutures.  The bowel segment was then folded over on itself and the reservoir formed with 3 successive applications of the SGIA Polysorb-75.  Between the staple lines, Vicryl sutures were placed and the defects closed with 3-0 Vicryl suture ligatures.,We then turned our attention to forming the ileocolonic anastomosis.  The left ureter was mobilized and brought underneath the sigmoid mesentery and brought through the mesentery of the terminal ileum and an end-to-side anastomosis performed with an open technique using interrupted 4-0 Vicryl sutures, and this was stented with a Cook 8.4-French ureteral stent, and this was secured to the bowel lumen with a 5-0 chromic suture.  The right ureter was brought underneath the pouch and placed in a stented fashion with an identical anastomosis.  We then brought the stents out through a separate incision cephalad in the pouch and they were secured with a 2-0 chromic suture.  A 24-French Malecot catheter was placed through the cecum and secured with a chromic suture.  The staple lines were then buried with a running 3-0 Vicryl two-layer suture and the open end of the pouch closed with a TA 60 Polysorb suture.  The pouch was filled to 240 cc and noted to be watertight, and the ureteral anastomoses were intact.,We then made a final inspection for hemostasis.  The cecostomy tube was then brought out to the right lower quadrant and secured to the skin with silk sutures.  We then matured our stoma through the umbilicus.  We removed the plug of skin through the umbilicus and delivered the ileal segment through this.  A portion of the ileum was removed and healthy, well-vascularized tissue was matured with interrupted 3-0 chromic sutures.  We left an 18-French Robinson through the stoma and secured this to the skin with silk sutures.  The Malecot and stents were also secured in a similar fashion.,The stoma was returned to the umbilicus after resecting the terminal ileum.,We then placed a large JP drain into both obturator fossae and brought it up the right lower quadrant.  Rectus fascia was closed with buried #2 Prolene stitch anchoring a new figure of 8 at each end tying the two stitches above and in the middle and underneath the fascia.  Interrupted stitches were placed as well.  The subcutaneous tissue was irrigated and skin closed with surgical clips.  The estimated blood loss was 2500 mL.  The patient received 5 units of packed red blood cells and 4 units of FFP.  The patient was then awakened, extubated, and taken on a stretcher to the recovery room in satisfactory condition.
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DESCRIPTION: Exploratory laparotomy, resection of small bowel lesion, biopsy of small bowel mesentery, bilateral extended pelvic and iliac lymphadenectomy (including preaortic and precaval, bilateral common iliac, presacral, bilateral external iliac lymph nodes), salvage radical cystoprostatectomy (very difficult due to previous chemotherapy and radiation therapy), and continent urinary diversion with an Indiana pouch.

The medical situation described involves a complex and extensive surgical procedure on a 65-year-old male with multiple serious health conditions, including high-grade invasive bladder cancer, carcinoid tumor of the small bowel, previous coronary issues, and challenges from chemotherapy and radiation therapy. The procedure itself is intricate, involving multiple surgical techniques and carries considerable risk, as evidenced by the significant blood loss and the need for multiple blood transfusions. Given the patient's complicated medical history and the severity of his diagnoses, the stakes of the situation are quite high. The outcomes of the surgery could significantly impact the patient's quality of life and survival, making it potentially life-saving but also fraught with risk.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Vaginal Delivery - Vacuum-Assisted

PREOPERATIVE DIAGNOSES,1.  A 40 weeks 6 days intrauterine pregnancy.,2.  History of positive serology for HSV with no evidence of active lesions.,3.  Non-reassuring fetal heart tones.,POST OPERATIVE DIAGNOSES,1.  A 40 weeks 6 days intrauterine pregnancy.,2.  History of positive serology for HSV with no evidence of active lesions.,3.  Non-reassuring fetal heart tones.,PROCEDURES,1.  Vacuum-assisted vaginal delivery of a third-degree midline laceration and right vaginal side wall laceration.,2.  Repair of the third-degree midline laceration lasting for 25 minutes.,ANESTHESIA: , Local.,ESTIMATED BLOOD LOSS: , 300 mL.,COMPLICATIONS:  ,None.,FINDINGS,1.  Live male infant with Apgars of 9 and 9.,2.  Placenta delivered spontaneously intact with a three-vessel cord.,DISPOSITION:  ,The patient and baby remain in the LDR in stable condition.,SUMMARY: , This is a 36-year-old G1 woman who was pregnant since 40 weeks 6 days when she was admitted for induction of labor for post dates with favorable cervix.  When she was admitted, her cervix was 2.5 cm dilated with 80% effacement.  The baby had a -2 station.  She had no regular contractions.  Fetal heart tones were 120s and reactive.  She was started on Pitocin for labor induction and labored quite rapidly.  She had spontaneous rupture of membranes with a clear fluid.  She had planned on an epidural; however, she had sudden rapid cervical change and was unable to get the epidural.  With the rapid cervical change and descent of fetal head, there were some variable decelerations.  The baby was at a +1 station when the patient began pushing.  I had her push to get the baby to a +2 station.  During pushing, the fetal heart tones were in the 80s and did not recover in between contractions.  Because of this, I recommended a vacuum delivery for the baby.  The patient agreed.,The baby's head was confirmed to be in the right occiput anterior presentation.  The perineum was injected with 1% lidocaine.  The bladder was drained.  The vacuum was placed and the correct placement in front of the posterior fontanelle was confirmed digitally.  With the patient's next contraction, the vacuum was inflated and a gentle downward pressure was used to assist with brining the baby's head to a +3 station.  The contraction ended.  The vacuum was released and the fetal heart tones remained in the, at this time, 90s to 100s.  With the patient's next contraction, the vacuum was reapplied and the baby's head was delivered to a +4 station.  A modified Ritgen maneuver was used to stabilize the fetal head.  The vacuum was deflated and removed.  The baby's head then delivered atraumatically.  There was no nuchal cord.  The baby's anterior shoulder delivered after a less than 30 second delay.  No additional maneuvers were required to deliver the anterior shoulder.  The posterior shoulder and remainder of the body delivered easily.  The baby's mouth and nose were bulb suctioned.  The cord was clamped x2 and cut.  The infant was handed to the respiratory therapist.,Pitocin was added to the patient's IV fluids.  The placenta delivered spontaneously, was intact and had a three-vessel cord.  A vaginal inspection revealed a third-degree midline laceration as well as a right vaginal side wall laceration.  The right side wall laceration was repaired with #3-0 Vicryl suture in a running fashion with local anesthesia.  The third-degree laceration was also repaired with #3-0 Vicryl sutures.  Local anesthesia was used.  The capsule was visible, but did not appear to be injured at all.  It was reinforced with three separate interrupted sutures and then the remainder of the incision was closed with #3-0 Vicryl in the typical fashion.,The patient tolerated the procedure very well.  She remains in the LDR with the baby.  The baby is vigorous, crying and moving all extremities.  He will go to the new born nursery when ready.  The total time for repair of the laceration was 25 minutes.
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DESCRIPTION: Vacuum-assisted vaginal delivery of a third-degree midline laceration and right vaginal side wall laceration and repair of the third-degree midline laceration lasting for 25 minutes.

obstetrics / gynecology, intrauterine pregnancy, non-reassuring fetal heart tones, vacuum-assisted vaginal delivery, vaginal side wall laceration, fetal heart tones, vaginal delivery, vacuum assisted, laceration, intrauterine, tones, contractions,

The situation involves a vacuum-assisted vaginal delivery, which is typically a high-stakes medical procedure due to the potential for complications for both the mother and the infant. There are several complicating factors mentioned, such as non-reassuring fetal heart tones, the need for rapid delivery, and a third-degree laceration. Although there were no complications reported post-operatively, the urgency and precision required in such deliveries, combined with the potential risks to both mother and child, make this scenario high-stakes.


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

Medical Specialty: Consult - History and Phy.
Sample Name: Gagging - 3-year-old

HISTORY OF PRESENT ILLNESS: , This is a 3-year-old female patient, who was admitted today with a history of gagging.  She was doing well until about 2 days ago, when she developed gagging.  No vomiting.  No fever.  She has history of constipation.  She normally passes stool every two days after giving an enema.  No rectal bleeding.  She was brought to the Hospital with some loose stool.  She was found to be dehydrated.  She was given IV fluid bolus, but then she started bleeding from G-tube site.  There was some fresh blood coming out of the G-tube site.  She was transferred to PICU.  She is hypertensive.  Intensivist Dr. X requested me to come and look at her, and do upper endoscopy to find the site of bleeding.,PAST MEDICAL HISTORY: , PEHO syndrome, infantile spasm, right above knee amputation, developmental delay, G-tube fundoplication.,PAST SURGICAL HISTORY: , G-tube fundoplication on 05/25/2007.  Right above knee amputation.,ALLERGIES:,  None.,DIET: , She is NPO now, but at home she is on PediaSure 4 ounces 3 times a day through G-tube, 12 ounces of water per day.,MEDICATIONS: , Albuterol, Pulmicort, MiraLax 17 g once a week, carnitine, phenobarbital, Depakene and Reglan.,FAMILY HISTORY:,  Positive for cancer.,PAST LABORATORY EVALUATION: , On 12/27/2007; WBC 9.3, hemoglobin 7.6, hematocrit 22.1, platelet 132,000.  KUB showed large stool with dilated small and large bowel loops.  Sodium 140, potassium 4.4, chloride 89, CO2 21, BUN 61, creatinine 2, AST 92 increased, ALT 62 increased, albumin 5.3, total bilirubin 0.1.  Earlier this morning, she had hemoglobin of 14.5, hematocrit 41.3, platelets 491,000.  PT 58 increased, INR 6.6 increased, PTT 75.9 increased.,PHYSICAL EXAMINATION:  ,VITAL SIGNS:  Temperature 99 degrees Fahrenheit, pulse 142 per minute, respirations 34 per minute, weight 8.6 kg.,GENERAL:  She is intubated.,HEENT:  Atraumatic.  She is intubated.,LUNGS:  Good air entry bilaterally.  No rales or wheezing.,ABDOMEN:  Distended.  Decreased bowel sounds.,GENITALIA:  Grossly normal female.,CNS:  She is sedated.,IMPRESSION: , A 3-year-old female patient with history of passage of blood through G-tube site with coagulopathy.  She has a history of G-tube fundoplication, developmental delay, PEHO syndrome, which is progressive encephalopathy optic atrophy.,PLAN:  ,Plan is to give vitamin K, FFP, blood transfusion.  Consider upper endoscopy.  Procedure and informed consent discussed with the family.
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DESCRIPTION: Pediatric Gastroenterology - History of gagging.

consult - history and phy., g-tube, peho syndrome, tube site, gagging, constipation, endoscopy, peho, hemoglobin, hematocrit, intubated, bleeding, blood, fundoplication, tube,

The situation involves a 3-year-old patient with complex medical history, presenting with potentially serious symptoms like bleeding from G-tube site and coagulopathy, leading to sedation and transfer to PICU. These symptoms indicate possible acute deterioration, requiring immediate medical intervention including endoscopy and potential surgical procedures. Given the patient's young age, underlying conditions, and current severe symptoms, this situation is high-stakes as it involves significant risk to the patient's health and requires urgent and careful medical management.


Medical Specialty: Orthopedic
Sample Name: Ganglion Excision

PREOPERATIVE DIAGNOSIS: , Ganglion of the left wrist.,POSTOPERATIVE DIAGNOSIS: , Ganglion of the left wrist.,OPERATION: , Excision of ganglion.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Less than 5 mL.,OPERATION: , After a successful anesthetic, the patient was positioned on the operating table.  A tourniquet applied to the upper arm.  The extremity was prepped in a usual manner for a surgical procedure and draped off.  The superficial vessels were exsanguinated with an elastic wrap and the tourniquet was then inflated to the usual arm pressure.  A curved incision was made over the presenting ganglion over the dorsal aspect of the wrist.  By blunt and sharp dissection, it was dissected out from underneath the extensor tendons and the stalk appeared to arise from the distal radiocapitellar joint and the dorsal capsule was excised along with the ganglion and the specimen was removed and submitted.  The small superficial vessels were electrocoagulated and instilled after closing the skin with 4-0 Prolene, into the area was approximately 6 to 7 mL of 0.25 Marcaine with epinephrine.  A Jackson-Pratt drain was inserted and then after the tourniquet was released, it was kept deflated until at least 5 to 10 minutes had passed and then it was activated and then removed in the recovery room.  The dressings applied to the hand were that of Xeroform, 4x4s, ABD, Kerlix, and elastic wrap over a volar fiberglass splint.  The tourniquet was released.  Circulation returned to the fingers.  The patient then was allowed to awaken and left the operating room in good condition.
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DESCRIPTION: Excision of ganglion of the left wrist.  A curved incision was made over the presenting ganglion over the dorsal aspect of the wrist.

orthopedic, curved incision, superficial vessels, tourniquet, excision, dorsal, wrist, ganglion

The details provided describe a surgical procedure for the excision of a ganglion cyst in the wrist, which is typically a routine and low-risk orthopedic surgery. The use of general anesthesia and the description of care and monitoring during the procedure do add some complexity, but the estimated blood loss is minimal, and the postoperative outcome indicates the patient left in good condition. The procedure is standard in nature and not life-threatening, which makes it a lower-stakes situation within a controlled surgical environment.


Medical Specialty: Podiatry
Sample Name: Onychomycosis - H&P

CHIEF COMPLAINT (1/1):, This 59 year old female presents today complaining that her toenails are discolored, thickened, and painful. Duration: Condition has existed for 6 months. Severity: Severity of condition is worsening.,ALLERGIES: ,Patient admits allergies to dairy products, penicillin.,MEDICATION HISTORY:, None.,PAST MEDICAL HISTORY:, Past medical history is unremarkable.,PAST SURGICAL HISTORY:, Patient admits past surgical history of eye surgery in 1999.,SOCIAL HISTORY:, Patient denies alcohol use, Patient denies illegal drug use, Patient denies STD history, Patient denies tobacco use.,FAMILY HISTORY:, Unremarkable.,REVIEW OF SYSTEMS:, Psychiatric: (+) poor sleep pattern, Respiratory: (+) breathing difficulties, respiratory symptoms.,PHYSICAL EXAM:, Patient is a 59 year old female who appears well developed, well nourished and with good attention to hygiene and body habitus. Toenails 1-5 bilateral appear crumbly, discolored - yellow, friable and thickened.,Cardiovascular: DP pulses palpable bilateral. PT pulses palpable bilateral. CFT immediate. No edema observed.  Varicosities are not observed.,Skin: Skin temperature of the lower extremities is warm to cool, proximal to distal. No skin rash, subcutaneous nodules, lesions or ulcers observed.,Neurological: Touch, pin, vibratory and proprioception sensations are normal. Deep tendon reflexes normal.,Musculoskeletal: Muscle strength is 5/5 for all groups tested. Muscle tone is normal. Inspection and palpation of bones, joints and muscles is unremarkable.,TEST RESULTS:, No tests to report at this time.,IMPRESSION:, Onychomycosis.,PLAN:, Debrided 10 nails.,PRESCRIPTIONS:, Penlac Dosage: 8% Topical Solution Sig:
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DESCRIPTION: Toenails are discolored, thickened, and painful - Onychomycosis

The situation described is medically significant but not life-threatening. Onychomycosis is a common fungal infection of the toenails that can cause discomfort and pain, as described by the patient. However, it typically does not lead to serious health complications if treated. The primary concern is patient discomfort and potential impact on quality of life, which are important but not immediately critical. The treatment plan involves debridement and prescription of Penlac, a topical antifungal agent, indicating that it is being addressed. However, there is an allergy to penicillin, which requires ensuring no cross-reactive medication is used. This situation is typical and routine in a podiatric context.


Medical Specialty: Surgery
Sample Name: Ventriculostomy Placement

PROCEDURE: , Placement of left ventriculostomy via twist drill.,PREOPERATIVE DIAGNOSIS:,  Massive intraventricular hemorrhage with hydrocephalus and increased intracranial pressure.,POSTOPERATIVE DIAGNOSIS: , Massive intraventricular hemorrhage with hydrocephalus and increased intracranial pressure.,INDICATIONS FOR PROCEDURE:  ,The patient is a man with a history of massive intracranial hemorrhage and hydrocephalus with intraventricular hemorrhage.  His condition is felt to be critical.  In a desperate attempt to relieve increased intracranial pressure, we have proposed placing a ventriculostomy.  I have discussed this with patient's wife who agrees and asked that we proceed emergently.,After a sterile prep, drape, and shaving of the hair over the left frontal area, this area is infiltrated with local anesthetic.  Subsequently a 1 cm incision was made over Kocher's point.  Hemostasis was obtained.  Then a twist drill was made over this area.  Bones strips were irrigated away.  The dura was perforated with a spinal needle.,A Camino monitor was connected and zeroed.  This was then passed into the left lateral ventricle on the first pass.  Excellent aggressive very bloody CSF under pressure was noted.  This stopped, slowed, and some clots were noted.  This was irrigated and then CSF continued.  Initial opening pressures were 30, but soon arose to 80 or a 100.,The patient tolerated the procedure well.  The wound was stitched shut and the ventricular drain was then connected to a drainage bag.,Platelets and FFP as well as vitamin K have been administered and ordered simultaneously with the placement of this device to help prevent further clotting or bleeding.
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DESCRIPTION: Placement of left ventriculostomy via twist drill.  Massive intraventricular hemorrhage with hydrocephalus and increased intracranial pressure.

surgery, intraventricular hemorrhage, hydrocephalus, intracranial pressure, camino monitor, twist drill, ventriculostomy, hemorrhage, intracranial, pressure, intraventricular

The procedure described is an emergency surgical intervention aimed at relieving life-threatening increased intracranial pressure due to a massive intraventricular hemorrhage with hydrocephalus. The surgery is performed on a patient in critical condition, and the outcome could be the difference between life and death. This makes the situation extremely high-stakes.


Medical Specialty: Orthopedic
Sample Name: CT Head, Facial Bones, Cervical Spine

EXAM: , CT head without contrast, CT facial bones without contrast, and CT cervical spine without contrast.,REASON FOR EXAM:,  A 68-year-old status post fall with multifocal pain.,COMPARISONS: , None.,TECHNIQUE: , Sequential axial CT images were obtained from the vertex to the thoracic inlet without contrast.  Additional high-resolution sagittal and/or coronal reconstructed images were obtained through the facial bones and cervical spine for better visualization of the osseous structures.,INTERPRETATIONS:,HEAD:,There is mild generalized atrophy.  Scattered patchy foci of decreased attenuation is seen in the subcortical and periventricular white matter consistent with chronic small vessel ischemic changes.  There are subtle areas of increased attenuation seen within the frontal lobes bilaterally.  Given the patient's clinical presentation, these likely represent small hemorrhagic contusions.  Other differential considerations include cortical calcifications, which are less likely.  The brain parenchyma is otherwise normal in attenuation without evidence of mass, midline shift, hydrocephalus, extra-axial fluid, or acute infarction.  The visualized paranasal sinuses and mastoid air cells are clear.  The bony calvarium and skull base are unremarkable.,FACIAL BONES:,The osseous structures about the face are grossly intact without acute fracture or dislocation.  The orbits and extra-ocular muscles are within normal limits.  There is diffuse mucosal thickening in the ethmoid and right maxillary sinuses.  The remaining visualized paranasal sinuses and mastoid air cells are clear.  Diffuse soft tissue swelling is noted about the right orbit and right facial bones without underlying fracture.,CERVICAL SPINE:,There is mild generalized osteopenia.  There are diffuse multilevel degenerative changes identified extending from C4-C7 with disk space narrowing, sclerosis, and marginal osteophyte formation.  The remaining cervical vertebral body heights are maintained without acute fracture, dislocation, or spondylolisthesis.  The central canal is grossly patent.  The pedicles and posterior elements appear intact with multifocal facet degenerative changes.  There is no prevertebral or paravertebral soft tissue masses identified.  The atlanto-dens interval and dens are maintained.,IMPRESSION:,1.Subtle areas of increased attenuation identified within the frontal lobes bilaterally suggesting small hemorrhagic contusions.  There is no associated shift or mass effect at this time.  Less likely, this finding could be secondary to cortical calcifications.  The patient may benefit from a repeat CT scan of the head or MRI for additional evaluation if clinically indicated.,2.Atrophy and chronic small vessel ischemic changes in the brain.,3.Ethmoid and right maxillary sinus congestion and diffuse soft tissue swelling over the right side of the face without underlying fracture.,4.Osteopenia and multilevel degenerative changes in the cervical spine as described above.,5.Findings were discussed with Dr. X from the emergency department at the time of interpretation.
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DESCRIPTION: CT head without contrast, CT facial bones without contrast, and CT cervical spine without contrast.

orthopedic, sagittal, coronal, soft tissue swelling, paranasal sinuses, mastoid air, acute fracture, maxillary sinuses, tissue swelling, underlying fracture, multilevel degenerative, ct head, soft tissue, facial bones, cervical spine, ct, facial, bones, spine, cervical

The CT findings reveal a 68-year-old patient who has fallen and presents with multiple areas of concern including potential small hemorrhagic contusions in the frontal lobes, chronic ischemic changes, and diffuse soft tissue swelling in the facial area. These findings, particularly the potential hemorrhagic contusions, which can indicate a traumatic brain injury, make this a high-stakes situation. Traumatic brain injuries can have serious implications especially considering the patient's age, which may predispose them to more severe outcomes. The need for potential follow-up imaging underscores the seriousness of the situation. Although there is no immediate evidence of midline shift or acute fracture, the presence of these injuries, especially after a fall, warrants close medical management.


Medical Specialty: General Medicine
Sample Name: Gen Med Progress Note - 3

CHIEF COMPLAINT:, Followup on diabetes mellitus, hypercholesterolemia, and sinusitis. ,SUBJECTIVE:,  A 70-year-old female who was diagnosed with diabetes mellitus last fall.  She has been checking her Accu-Cheks generally once a day, and they range from 82 to a high of 132.  She feels well.  She walks 1-2 miles most days.  If the weather is bad, they go to a local mall.  Otherwise they walk outside.  She does complain of some sinus congestion and drainage for the last several days.  She is up-to-date on her mammogram that she had at the Baylis Building.  She sees Dr. Cheng for her gynecological care.  She is a nonsmoker.  Denies abdominal pain, nausea, vomiting, diarrhea, constipation, blood in her urine, blood in her stools.  She has nocturia x 1.  Denies swelling in her ankles.  She checks her feet regularly., ,PAST MEDICAL HISTORY:,  Refer to chart.,MEDICATIONS:, Refer to chart.,ALLERGIES:, Refer to chart.,PHYSICAL EXAMINATION: ,Vitals: Wt:  185 B/P: 142/70.  When she checks it at the mall and other places, it is usually about 120/56. T: 96.5 P:  84 and regular.,General: A 70-year-old female who does not appear to be in acute distress.  ,HEENT: She has frontal and maxillary sinus tenderness on the right to palpation.  The right TM is slightly dull.
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DESCRIPTION: Sample progress note - Gen Med.

Sample progress note - Gen Med.

The situation involves a routine follow-up examination of a 70-year-old female patient with diabetes mellitus, hypercholesterolemia, and sinusitis. The patient's diabetes seems well-managed, as indicated by her Accu-Chek readings and her active lifestyle. There is some concern with her blood pressure readings, as there is a noted difference between at-home and clinical measurements. Her sinusitis might need attention, given the symptoms. However, there are no immediate life-threatening issues or critical symptoms mentioned. It involves common chronic conditions manageable in an outpatient setting. Thus, this situation does not represent a high-stakes scenario.


Medical Specialty: Discharge Summary
Sample Name: Discharge Summary - 17

FINAL DIAGNOSIS/REASON FOR ADMISSION:,1.  Acute right lobar pneumonia.,2.  Hypoxemia and hypotension secondary to acute right lobar pneumonia.,3.  Electrolyte abnormality with hyponatremia and hypokalemia - corrected.,4.  Elevated liver function tests, etiology undetermined.,5.  The patient has a history of moderate-to-severe dementia, Alzheimer's type.,6.  Anemia secondary to current illness and possible iron deficiency.,7.  Darkened mole on the scalp, status post skin biopsy, pending pathology report.,OPERATION AND PROCEDURE: , The patient underwent a scalp skin biopsy with pathology specimen obtained on 6/11/2009.  Dr. X performed the procedure, thoracentesis on 6/12/2009 both diagnostic and therapeutic.  Dr. Y's results pending.,DISPOSITION: , The patient discharged to long-term acute facility under the care of Dr. Z.,CONDITION ON DISCHARGE: , Clinically improved, however, requiring acute care.,CURRENT MEDICATIONS:  ,Include those on admission combined with IV Flagyl 500 mg every 8 hours and Levaquin 500 mg daily.,HOSPITAL SUMMARY: , This is one of several admissions for this 68-year-old female who over the initial 48 hours preceding admission had a complaint of low-grade fever, confusion, dizziness, and a nonproductive cough.  Her symptoms progressed and she presented to the emergency room at Brighton Gardens where a chest x-ray revealed evolving right lobar infiltrate.  She was started on antibiotics.  Infectious Disease was consulted.  She was initially begun on vancomycin.  Blood, sputum, and urine cultures were obtained; the results of which were negative for infection.  She was switched to IV Levaquin and received IV Flagyl for possible C. diff colitis as well as possible cholecystitis.  During her hospital stay, she initially was extremely relatively hypotensive with mild symptoms and she became dizzy with upright positioning.  Her systolic blood pressure was 60-70 mmHg despite rather aggressive IV fluid management up to 250 mL an hour.  She was seen in consultation by Dr. Y who monitored her fluid and pulmonary treatment.  Due to some elevated liver function tests, she was seen in consultation by Dr. X.  An ultrasound was negative; however, she did undergo CT scan of the chest and abdomen and there was a suspicion of fluid circling the gallbladder.  A HIDA scan was performed and revealed no evidence of gallbladder dysfunction.  Liver functions were monitored throughout her stay and while elevated, did reduce to approximately 1.5 times normal value.  She also was seen in consultation by Infectious Disease who followed her for several days and agreed with current management of antibiotics.  Over her week-stay, the patient was moderately hypoxemic with room air pulse oximetry of 90%.  She was placed on incentive spirometry and over the succeeding days, she did have improved pulmonary function.,LABORATORY TESTS: , Initially revealed a white count of 13,000, however, approximately 24 hours following admission her white count stabilized and in fact remained normal throughout her stay.  Blood cultures were negative at 5 days.  Sputum culture was negative.  Urine culture was negative and thoracentesis culture negative at 24 hours.  The patient did receive 2 units of packed red cells with the hemoglobin drop to 9 for cardiovascular support, as no evidence of GI bleeding was obtained.  Her most recent blood work on 6/14/2009 revealed a white count of 7000 and hemoglobin of 12.1 with a hematocrit of 36.8.  Her PT and PTT were normal.  Occult blood studies were negative for occult blood.  Hepatitis B antigen was negative.  Hepatitis A antibody IgM was negative.  Hepatitis B core IgM negative, and hepatitis C core antibody was negative.  At the time of discharge on 6/14/2009, sodium was 135, potassium was 3.7, calcium was 8.0, her ALT was 109, AST was 70, direct bilirubin was 0.2, LDH was 219, serum iron was 7, total iron unbound 183, and ferritin level was 267.,At the time of discharge, the patient had improved.  She complained of some back discomfort and lumbosacral back x-ray did reveal some evidence of mild degenerative disk disease with no obvious compression fracture acute noted and she will be followed by Dr. Z.
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DESCRIPTION: The patient underwent a scalp skin biopsy with pathology specimen obtained.   At the time of discharge, the patient had improved.

discharge summary, pneumonia, hypoxemia, hypotension, electrolyte abnormality, anemia, scalp skin biopsy, liver function tests, lobar pneumonia, infectious disease, skin biopsy, white count, cultures

The discharge summary indicates a complex medical situation with multiple diagnoses, including acute pneumonia leading to hypoxemia and hypotension, electrolyte imbalances, and elevated liver function tests. Additionally, the patient has a history of moderate-to-severe dementia, making her care more complicated. The involvement of multiple specialists and the fact that she is being discharged to a long-term acute care facility highlight the severity of her condition and the need for continued acute care. However, the patient is clinically improved, and her conditions are managed and monitored. This situation is high-stakes due to the complexity and seriousness of the medical conditions, the critical interventions required during the hospital stay, and the continuing need for acute care post-discharge.


Medical Specialty: Orthopedic
Sample Name: Austin-Moore Bipolar Hemiarthroplasty

PREOPERATIVE DIAGNOSIS:,  Displace subcapital fracture, left hip.,POSTOPERATIVE DIAGNOSIS: , Displace subcapital fracture, left hip.,PROCEDURE PERFORMED: , Austin-Moore bipolar hemiarthroplasty, left hip utilizing a medium fenestrated femoral stem with a medium 0.8 mm femoral head, a 50 mm bipolar cup.,PROCEDURE: , The patient was taken to OR #2, administered a subarachnoid block anesthetic and was then positioned in the right lateral decubitus position on the beanbag on the operative table.  The right lower extremity was protectively padded.  The left leg was propped with multiple blankets.  The hip was then prepped and draped in the usual manner.  A posterior incision was made on the posterolateral aspect of the left hip down to the skin and subcutaneous tissues.  Hemostasis was achieved utilizing electrocautery.  Gluteus fascia was incised in line with a skin incision and the muscle was split posteriorly.  The external rotators were identified after removal of the trochanteric bursa.  Hemostat was utilized to separate the external rotators from the underlying capsule, they were then transected off from their attachment at the posterior intertrochanteric line.  They were then reflected distally.  The capsule was then opened in a T-fashion utilizing the cutting cautery.  Fraction hematoma exuded from the hip joint.  The cork screw was then impacted into the femoral head and it was removed from the acetabulum.  Bone fragments were removed from the neck and acetabulum.  The acetabulum was then inspected and noted to be free from debris.  The proximal femur was then delivered into the wound with the hip internally rotated.,A mortise chisel was then utilized to take the cancellous bone from the proximal femur.  The T-handle broach was then passed down the canal.  The canal was then sequentially broached up to a medium broach.  The calcar was then plained with the hand plainer.  The trial components were positioned into place.  The medium component fit fairly well with the medium 28 mm femoral head.  Once the trial reduction was performed, the hip was taken through range of motion.  There was physiologic crystalling with longitudinal traction.  There was no tendency towards dislocation with flexion of the hip past 90 degrees.  The trial implants were then removed.  The acetabulum was then copiously irrigated with gentamicin solution and suctioned dry.  The medium fenestrated femoral stem was prepared by placing a large segment of bone from the femoral head into the fenestration making it a little larger than the width of the implant to provide a press fit.  The implant was then impacted into place.  The 28 mm femoral head was impacted on the mortise stapler of the femoral stem followed by placement of the 50 mm bipolar cup.  The acetabulum was once again inspected, was free of debris.  The hip was reduced.  It was taken through full range of motion.  There was no tendency for dislocation.  The wound was copiously irrigated with gentamicin solution.  The capsule was then repaired with interrupted #1 Ethibond suture.  External rotators were then reapproximated to the posterior intertrochanteric line utilizing #1 Ethibond in a modified Kessler type stitch.  The wound was once again copiously irrigated with gentamicin solution and suctioned dry.  Gluteus fascia was approximated with interrupted #1 Ethibond.  Subcutaneous layers were approximated with interrupted #2-0 Vicryl and skin approximated with staples.  A bulky dressing was applied to the wound.  The patient was then transferred to the hospital bed, an abductor pillow was positioned into place.  Circulatory status was intact to the extremity at completion of the case.
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DESCRIPTION: Austin-Moore bipolar hemiarthroplasty, left hip utilizing a medium fenestrated femoral stem with a medium 0.8 mm femoral head, a 50 mm bipolar cup.  Displace subcapital fracture, left hip.

orthopedic, austin moore, bipolar hemiarthroplasty, femoral head, femoral, hip, hemiarthroplasty, ethibond, acetabulum,

This situation involves an orthopedic surgical procedure for a displaced subcapital fracture of the hip, requiring detailed preoperative and postoperative care management. The stakes are fairly high, as surgical interventions, particularly hip surgeries, involve significant risks such as infection, blood loss, and potential complications affecting mobility and recovery. While not life-threatening if managed properly, the procedure does have a substantial impact on the patient's health and quality of life, and requires precise execution and postoperative care to ensure successful healing and function restoration.