Medical Specialty: Dermatology
Sample Name: Acne Vulgaris

ACNE VULGARIS,, commonly referred to as just acne, is a chronic inflammation of the skin that occurs most often during adolescence but can occur off and on throughout life.  The skin eruptions most often appear on the face, chest, back and upper arms and are more common in males than females.,SIGNS AND SYMPTOMS:,*  Blackheads the size of a pinhead.,*  Whiteheads similar to blackheads.,*  Pustules - lesions filled with pus.,*  Redness and inflamed skin.,*  Cysts - large, firm swollen lesions in severe acne.,*  Abscess - infected lesion that is swollen, tender, inflamed, filled with pus, also seen in severe acne.,CAUSES:,Oil glands in the skin become plugged for reasons unknown but during adolescence, sex-hormone changes play some role.  When oil backs up in the plugged gland, a bacteria normally present on skin causes an infection.  Acne is NOT caused by foods, uncleanliness or masturbation.  Cleaning the skin can decrease its severity but sexual activity has no effect on it.  A family history of acne can indicate if an individual will get acne and how severe it might be.  Currently, acne can't be prevented.,ACNE CAN BE BROUGHT ON OR MADE WORSE BY:,*  Hot or cold temperatures.,*  Emotional stress.,*  Oily skin.,*  Endocrine (hormone) disorder.,*  Drugs such as cortisones, male hormones, or oral contraceptives.,*  Some cosmetics.,*  Food sensitivities.  Again, foods do not cause acne but some certain ones may make it worse.  To discover any food sensitivities, eliminate suspicious foods from your diet and then start eating them again one at a time.  If acne worsens 2-3 days after consumption, then avoid this food.  Acne usually improves in summer so some foods may be tolerated in summer that can't be eaten in winter.,TREATMENT:,*  Most cases of acne respond well to treatment and will likely disappear once adolescence is over.  Even with adequate treatment, acne will tend to flare up from time to time and sometimes permanent facial scars or pitting of the skin may occur.,*  If your skin is oily, gently clean face with a fresh, clean wash cloth using unscented soap for 3- 5 minutes; an antibacterial soap may work better.  A previously used wet washcloth will harbor bacteria.  Don't aggressively scrub tender lesions as this may spread infection; be gentle.  Rinse the soap off for a good 1-2 minutes.  Dry face carefully with a clean towel and use an astringent such as rubbing alcohol that will remove the skin oil.,OTHER TIPS THAT MAY HELP ACNE:,*  Shampoo hair at least twice a week.  Keep hair off of face even while sleeping as hair can spread oil and bacteria.  If you have dandruff, use a dandruff shampoo.  Avoid cream hair rinses.,*  Wash sweat and skin oil off as soon as possible after sweating and exercising.,*  Use thinner, water-based cosmetics instead of the heavier oil-based ones.,*  Avoid skin moisturizers unless recommended by your doctor.,*  Do not squeeze, pick, rub or scratch your skin or the acne lesions.  This may damage the skin causing scarring and delay healing of acne.  Only a doctor should remove blackheads.,*  Keep from resting face on hands while reading, studying or watching TV.,*  Try to avoid pressing the phone receiver on you chin while talking on the phone.,*  Ultraviolet light may be a treatment recommended by your doctor but this is by no means a license to sunbathe!  Don't use the sun to treat acne.,*  Dermabrasion may be another option to treat acne scars.  This is a type of cosmetic surgery to help remove unsightly scars.,MEDICATIONS THAT MAY BE PRESCRIBED TO HELP ACNE INCLUDE:,*  Oral or topical antibiotics.,*  Cortisone injections into acne lesions.,*  Oral contraceptives.,*  Tretinoin, which may increase sun sensitivity and excessive dryness,  is not recommended during pregnancy.,*  Accutane (isotretinoin) is a powerful drug to treat acne but causes birth defects.  A woman taking this drug,must be on two types of birth control and have negative pregnancy tests.  This drug also increases sun,sensitivity.  Other more serious side effects can occur and your doctor will discuss those with you if Accutane is to be prescribed.,TETRACYCLINE:,Tetracycline is a very safe antibiotic.  It is not related to penicillin and an allergy to it is unusual.  There are several potential side effects:,1.  Tetracycline can cause nausea or heartburn.,2.  Tetracycline can cause vaginitis.,3.  Tetracycline can cause excessive sun burn.,CAUTIONS ON TETRACYCLINE:,1.  Do not take Tetracycline with milk or milk products (ice cream, cheese, yogurt, etc.).  This will cancel out the Tetracycline.  Separate the Tetracycline from these products by one and one-half hours before and after each capsule.  Do have a small amount of non milk-containing food in your stomach first to prevent nausea.,2.  Do not take Tetracycline if you are pregnant.
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DESCRIPTION: A simple note on Acne Vulgaris.

A simple note on Acne Vulgaris.

The situation involves a medical condition, acne vulgaris, which is a common dermatological issue. Although acne can impact quality of life and self-esteem, especially in teenagers, it is not typically life-threatening. However, some treatments, like Accutane (isotretinoin), require careful management due to potential severe side effects, particularly in relation to pregnancy. While acne treatment is an important aspect of dermatological practice, it generally doesn't involve immediate life-or-death decisions, and thus doesn't constitute a high-stakes situation.

This analysis considers the chronic nature of the condition and potential severe side effects of certain medications which require careful management, but ultimately the overall risk associated with acne vulgaris itself is relatively low.


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: Gen Med Consult - 35

Chief Complaint:, Confusion and hallucinations.,History of Present Illness:, The patient was a 27-year-old Hispanic man who presented to St. Luke's Episcopal Hospital with a five day history of confusion and hallucinations. The patient was doing well until three months prior to admission when he developed wheezing and shortness of breath upon exertion. He was seen by his primary care physician and was prescribed Salmeterol and Fluticasone nasal inhaler for presumed asthma. His wheezing improved with treatment.,Over the five days prior to admission, his family noticed the patient's increasing confusion and bizarre behavior. The patient was intermittently unable to recognize his family members or surroundings. He was restless and anxious, paced the floor at night, and complained of insomnia. He stated he was unable to sleep because he feared his family was trying to hurt him. When he did sleep, he described night terrors. He also complained of both auditory and visual hallucinations. He stated the voices "told him to do good things". He denied any previous history of depression or manic episodes. The patient denied suicidal or homicidal ideation. He admitted he had recently lost weight although he was unable to quantify how much. He stated his appetite was good, but he had not been eating for fear of being poisoned.,The patient denied having headaches or a history of trauma. He denied fevers or chills but he complained of recent night sweats. He denied nausea, vomiting, diarrhea, or dysuria. He denied chest pain, palpitations, or episodic flushing; but he complained of lightheadedness. He denied orthopnea or paroxysmal nocturnal dyspnea. The shortness of breath symptoms had resolved.,Past Medical History:, None. No history of hypertension or of cardiac, renal, lung, or liver disease.,Past Surgical History:, None,Past Psychological History: None,Social History:, The patient was from Brazil. He moved to the United States one year ago. He denied any history of tobacco, alcohol, or illicit drug use. He was married and monogamous. He worked as an engineer/manager, and stated that his job was "very stressful". He had recently been admitted to an MBA program. The patient denied recent travel or exposures of any kind.,Family History:, The patient had a second-degree relative with a history of depression and "nervous breakdown".,Allergies:, There were no known drug allergies.,Medications:, Prescribed medications were Salmeterol inhaler, prn; and Fluticasone nasal inhaler. The patient was taking no over the counter or alternative medicines.,Physical Examination:, The patient was a 27-year-old Hispanic man who presented with symptoms of confusion and hallucinations. He was a thin man but appeared to be well developed and well nourished. The patient paced the room during the examination. He appeared anxious and distracted. He was coherent, yet he had poor concentration and was unable to cooperate fully with the examination. The patient had a pulse rate of 110 beats per minute and blood pressure of 186/101 mm Hg when reclining; and a pulse rate of 122 beats per minute and blood pressure of 166/92 mm Hg when standing. His oral temperature was 100.8 degrees Fahrenheit, and his respiratory rate was 12 breaths per minute.,HEENT: Conjunctivae were pink; sclerae anicteric; mucous membranes moist and pink without lesions.,NECK: The neck was supple, normal jugular venous pressure, no carotid bruits, no thyromegaly.,LUNGS: The lungs were clear to auscultation bilaterally; no wheezes, rales or rhonchi.,HEART: The heart had a regular rhythm, tachycardic, II/VI systolic ejection murmur LUSB, no rubs or gallops, PMI nondisplaced, hyperdynamic precordium.,ABDOMEN: The abdomen was soft, nontender and nondistended; normoactive bowel sounds, no hepatosplenomegaly, no masses; positive bruit heard throughout mid-abdomen, positive bilateral femoral bruits.,EXTREMITIES: No clubbing, cyanosis, or edema; 2+ pulses.,GENITOURINARY: Normal male phallus, no testicular masses.,RECTAL: Guaiac negative, no masses.,LYMPH NODES: Negative in the anterior and posterior clavicular, supraclavicular, axillary, and inguinal regions.,SKIN: Acneiform eruption over back and trunk, no papules or vesicles.,NEUROLOGICAL EXAMINATION: The patient was alert and oriented to self and year, but not to month or place. He had difficulty with mathematics and following commands (when asked to stand on his heels, the patient stood on his toes and turned on the television). Cranial nerves II-XII intact, motor 5/5 throughout all extremities; reflexes 2+ and symmetrical throughout. Sensory: Intact to light touch, vibration, proprioception, and temperature. Cerebellar: intact finger to nose, no ataxia. Romberg negative.,PSYCHOLOGICAL EXAMINATION: The patient's mood was elevated and euphoric; affect was appropriate; his speech was normal in rate, volume, and tone.,Hospital Course:, The patient was admitted to St. Luke's Episcopal Hospital and a workup for his altered mental status was begun. The following studies were performed:,Twelve-lead EKG: sinus tachycardia.,CXR (PA/lat): normal cardiac silhouette and normal lung fields.,CT scan of head without contrast: ventricles were normal in size and position. There was no evidence of mass or hemorrhage.,Lumbar puncture: clear, colorless; WBC--0; RBC--56; protein--45; glucose--126; VDRL--negative; cryptococcal Ag--negative; cultures--negative.,MRI with gadolinium: no discrete areas of abnormal signal intensity.,EEG: no focal or epileptiform activity.,The patient was treated with haldol and risperidone for his agitation, and further diagnostic testing was performed.
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DESCRIPTION: Patient with confusion and hallucinations.

The situation involves a 27-year-old patient with acute confusion and hallucinations, significant changes in mental status, and potential cardiovascular symptoms, including high blood pressure and a systolic murmur. This suggests a potentially serious underlying condition that may require urgent diagnosis and treatment. Furthermore, the psychiatric symptoms like hallucinations and paranoia significantly impact the patient’s safety and ability to function. These factors together indicate a situation with potentially severe health consequences, making it high-stakes.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: ENT - Otolaryngology
Sample Name: Myringotomy/Tube Insertion

PREOPERATIVE DIAGNOSES:,  Chronic otitis media with effusion, conductive hearing loss, and recurrent acute otitis media.,POSTOPERATIVE DIAGNOSES:,  Chronic otitis media with effusion, conductive hearing loss, and recurrent acute otitis media.,OPERATION: , Bilateral myringotomies, insertion of PE tubes, and pharyngeal anesthesia.,ANESTHESIA:  ,General via facemask.,ESTIMATED BLOOD LOSS: , None.,COMPLICATIONS: , None.,INDICATIONS:  ,The patient is a one-year-old with history of chronic and recurrent episodes of otitis media with persistent middle ear effusions resistant to medical therapy.,PROCEDURE: , The patient was brought to the operating room, was placed in supine position.  General anesthesia was begun via face mask technique.  Once an adequate level of anesthesia was obtained, the operating microscope was brought, positioned and visualized the right ear canal.  A small amount of wax was removed with a loop.  A 4-mm operating speculum was then introduced.  An anteroinferior quadrant radial myringotomy was then performed.  A large amount of mucoid middle ear effusion was aspirated from the middle ear cleft.  Reuter bobbin PE tube was then inserted, followed by Floxin otic drops and a cotton ball in the external meatus.  Head was then turned to the opposite side, where similar procedure was performed.  Once again, the middle ear cleft had a mucoid effusion.  A tube was inserted to an anteroinferior quadrant radial myringotomy.,Anesthesia was then reversed and the patient was transported to the recovery room having tolerated the procedure well with stable signs.
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DESCRIPTION: Bilateral myringotomies, insertion of PE tubes, and pharyngeal anesthesia.

ent - otolaryngology, bilateral myringotomies, insertion of pe tubes, chronic otitis media, conductive hearing loss, recurrent acute otitis media, reuter bobbin, radial myringotomy, ear cleft, pe tubes, middle ear, otitis media, effusion, otitis, media, ear, anesthesia

The procedure described is a myringotomy with the insertion of PE (pressure equalization) tubes, commonly performed on children with chronic and recurrent otitis media. Although surgery always comes with some level of risk, this is a relatively routine and low-risk procedure in pediatric ENT. The potential complications are generally minimal, and the document states there were no complications, estimated blood loss was none, and the patient tolerated the procedure well. While it involves general anesthesia, which always adds some risk and consideration, the stakes compared to many other surgeries are relatively low. Therefore, it's not a high-stakes situation in the context of surgical procedures.


Medical Specialty: Radiology
Sample Name: MRI Wrist - 1

FINDINGS:,There are posttraumatic cysts along the volar midline and volar lateral aspects of the lunate which are likely posttraumatic. There is no acute marrow edema (series #12 images #5-7). Marrow signal is otherwise normal in the distal radius and ulna, throughout the carpals and throughout the proximal metacarpals.,There is a partial tear of the volar component of the scapholunate ligament in the region of the posttraumatic lunate cyst with retraction and thickening towards the scaphoid (series #6 image #5, series #8 images #22-36). There is tearing of the membranous portion of the ligament. The dorsal component is intact.,The lunatotriquetral ligament is thickened and lax, but intact (series #8 image #32).,There is no tearing of the radial or ulnar attachment of the triangular fibrocartilage (series #6 image #7). There is a mildly positive ulnar variance. Normal ulnar collateral ligament.,The patient was positioned in dorsiflexion. Carpal alignment is normal and there are no tears of the dorsal or ventral intercarpal ligaments (series #14 image #9).,There is a longitudinal split tear of the ECU tendon which is enlarged both at the level of and distal to the ulnar styloid with severe synovitis (series #4 images #8-16, series #3 images #9-16).,There is thickening of the extensor tendon sheaths within the fourth dorsal compartment with intrinsically normal tendons (series #4 image #12).,There is extensor carpi radialis longus and brevis synovitis in the second dorsal compartment (series #4 image #13).,Normal flexor tendons within the carpal tunnel. There is mild thickening of the tendon sheaths and the median nerve demonstrates increased signal without compression or enlargement (series #3 image #7, series #4 image #7).,There are no pathological cysts or soft tissue masses.,IMPRESSION:,Partial tear of the volar and membranous components of the scapholunate ligament with an associated posttraumatic cyst in the lunate. There is thickening and laxity of the lunatotriquetral ligament.,Longitudinal split tear of the ECU tendon with tendinosis and severe synovitis.,Synovitis of the second dorsal compartment and tendon sheath thickening in the fourth dorsal compartment.,Tendon sheath thickening within the carpal tunnel with increased signal within the median nerve.
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DESCRIPTION: Patient with wrist pain and swelling, status post injury.

radiology, fourth dorsal compartment, tendon sheath thickening, tendon sheaths, dorsal compartment, volar, carpals, tear, ulnar, synovitis, sheaths, ligament, thickening, dorsal, tendon, injury,

The MRI findings reveal several issues including partial ligament tears, synovitis, and a tendon split tear, which are orthopedic concerns that can impact wrist function and cause pain, but they are not life-threatening or immediately critical in a broader context. These issues are generally managed through medical intervention, possibly including therapy or surgery, but are relatively common in orthopedic practice and are not emergencies.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Transesophageal Echocardiography Probe

INDICATIONS FOR PROCEDURE:,  Impending open heart surgery for closure of ventricular septal defect in a 4-month-old girl.,Procedures were done under general anesthesia.  The patient was already in the operating room under general anesthesia.  Antibiotic prophylaxis with cefazolin and gentamicin was already given prior to beginning the procedures.,PROCEDURE #1:,  Insertion of transesophageal echocardiography probe.,DESCRIPTION OF PROCEDURE #1: , The probe was well lubricated and with digital manipulation, was passed into the esophagus without resistance.  The probe was placed so that the larger diameter was in the anterior-posterior position during insertion.  The probe was used by the pediatric cardiologist for preoperative and postoperative diagnostic echocardiography.  At the end, it was removed without trauma and there was no blood tingeing.  It is to be noted that approximately 30 minutes after removing the cannula, I inserted a 14-French suction tube to empty the stomach and there were a few mL of blood secretions that were suctioned.  There was no overt bleeding.,PROCEDURE #2: , Attempted and unsuccessful insertion of arterial venous lines.,DESCRIPTION OF PROCEDURE #2:,  Both groins were prepped and draped.  The patient was placed at 10 degrees head-up position.  A Cook 4-French double-lumen 8-cm catheter kit was opened.  Using the 21-gauge needle that comes with the kit, several attempts were made to insert central venous and then an arterial line in the left groin.  There were several successful punctures of these vessels, but I was unable to advance Seldinger wire.  After removal of the needles, the area was compressed digitally for approximately 5 minutes.  There was a small hematoma that was not growing.  Initially, the left leg was mildly mottled with prolonged capillary refill of approximately 3 seconds.  Using 1% lidocaine, I infiltrated the vessels of the groin both medial and lateral to the vascular sheath.  Further observation, the capillary refill and circulation of the left leg became more than adequate.  The O2 saturation monitor that was on the left toe functioned well throughout the procedures, from the beginning to the end.  At the end of the procedure, the circulation of the leg was intact.,
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DESCRIPTION: Insertion of transesophageal echocardiography probe and unsuccessful insertion of arterial venous lines.

cardiovascular / pulmonary, impending open heart surgery, ventricular septal defect, antibiotic prophylaxis, cefazolin, transesophageal echocardiography probe, arterial venous lines, groin, transesophageal echocardiography, echocardiography probe, insertion, transesophageal, arterial, venous, groins, echocardiography, probe

The situation involves a medical procedure on a 4-month-old infant who is about to undergo open heart surgery for a serious condition: closure of a ventricular septal defect. The use of transesophageal echocardiography is a critical component of surgical planning and safety for such procedures. Moreover, the difficulty encountered in inserting arterial venous lines, despite resolving without long-term harm, indicates the complexity and potential risk involved in the procedure. The patient's age and the condition being treated both contribute to the high-stakes nature of the situation, as cardiovascular and pulmonary procedures in very young children require careful monitoring and skill. Therefore, the scenario carries significant risks to the patient's health, but the situation did stabilize, reducing the urgency somewhat.


Medical Specialty: Surgery
Sample Name: Juxtarenal Abdominal Aortic Aneurysm Repair

PREOPERATIVE DIAGNOSIS:  Large juxtarenal abdominal aortic aneurysm.,POSTOPERATIVE DIAGNOSIS:  Large juxtarenal abdominal aortic aneurysm.,ANESTHESIA:  General endotracheal anesthesia.,OPERATIVE TIME:  Three hours.,ANESTHESIA TIME:  Four hours.,DESCRIPTION OF PROCEDURE:  After thorough preoperative evaluation, the patient was brought to the operating room and placed on the operating table in supine position and after placement of upper extremity IV access and radial A-line, general endotracheal anesthesia was induced.  A Foley catheter was placed and a right internal jugular central line was placed.  The chest, abdomen, both groin, and perineum were prepped widely with Betadine and draped as a sterile field with an Ioban drape.  A long midline incision from xiphoid to pubis was created with a scalpel and the abdomen was carefully entered.  A sterile Omni-Tract was introduced into the field to retract the abdominal wall and gentle exploration of the abdomen was performed.  With the exception of the vascular findings to be described, there were no apparent intra-abdominal abnormalities.,The transverse colon retracted superiorly.  The small bowel was wrapped in moist green towel and retracted in the right upper quadrant.  The posterior peritoneum overlying the aneurysm was scribed mobilizing the ligament of Treitz thoroughly ligating and dividing the inferior mesenteric vein.  Dissection continued superiorly to identify the left renal vein and the right and left inferior renal arteries.  The mid left renal artery was likewise identified.  The perirenal aorta was prepared for clamp superior to the inferior left renal artery.  During this portion of the dissection, the patient was given multiple small doses of intravenous mannitol to establish an osmotic diuresis.  The distal dissection was then completed exposing each common iliac artery.  The arteries were suitable for control.,The patient was then given 8000 units of intravenous sodium heparin and systemic anticoagulation verified by activated clotting time.  The aneurysm was repaired.,First, the common carotid arteries were controlled with atraumatic clamps.  The inferior left renal artery was controlled with a microvascular clamp and a straight aortic clamp was used to control the aorta superior to this renal artery.  The aneurysm was opened on the right anterior lateral aspect and an endarterectomy of the aneurysm sac was performed.  There was a high-grade stenosis at the origin of the inferior mesenteric artery and an eversion endarterectomy was performed at this site.  The vessel was controlled with a microvascular clamp.  Two pairs of lumbar arteries were oversewn with 2-0 silk.  A 14 mm Hemashield tube graft was selected and sewn end-to-end fashion to the proximal aorta using a semi continuous 3-0 Prolene suture.  At the completion of anastomosis three patch stitches of 3-0 Prolene were required for hemostasis.  The graft was cut to appropriate length and sewn end-to-end at the iliac bifurcation using semi-continuous 3-0 Prolene suture.  Prior to completion of this anastomosis, the graft was flushed of air and debris and blood flow was reestablished slowly to the distal native circulation first to the pelvis with external compression on the femoral vessels and finally to the distal native circulation.  The distal anastomosis was competent without leak.,The patient was then given 70 mg of intravenous protamine and final hemostasis obtained using electrocoagulation.  The back bleeding from the inferior mesenteric artery was assessed and was pulsatile and vigorous.  The colon was normal in appearance and this vessel was oversewn using 2-0 silk.  The aneurysm sac was then closed about the grafts snuggly using 3-0 PDS in a vest-over-pants fashion.  The posterior peritoneum was reapproximated using running 3-0 PDS.  The entire large and small bowel were inspected and these structures were well perfused with a strong pulse within the SMA normal appearance of the entire viscera.  The NG tube was positioned in the fundus of the stomach and the viscera returned to their anatomic location.  The midline fascia was then reapproximated using running #1 PDS suture.  The subcutaneous tissues were irrigated with bacitracin and kanamycin solution.  The skin edges coapted using surgical staples.,At the conclusion of the case, sponge and needle counts were correct and a sterile occlusive compressive dressing was applied.
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DESCRIPTION: Repair of juxtarenal abdominal aortic aneurysm with 14 mm Hemashield tube graft.

surgery, inferior left renal artery, semi continuous prolene suture, juxtarenal abdominal aortic aneurysm, inferior mesenteric artery, continuous prolene suture, abdominal aortic aneurysm, hemashield tube, inferior mesenteric, renal artery, aortic aneurysm, aneurysm, iliac, endarterectomy, viscera, hemashield, abdomen, prolene, arteries, juxtarenal, graft, aortic, endotracheal, renal, artery,

The procedure described is a juxtarenal abdominal aortic aneurysm repair, which is a complex and high-risk surgery. Juxtarenal aneurysms involve the section of the aorta just below the renal arteries, and repairing them requires meticulous surgical technique to avoid complications such as renal damage, bleeding, or ischemia. The use of a 14 mm Hemashield tube graft indicates significant aortic reconstruction. The risks involved in this surgical procedure, including the potential for loss of blood flow to critical organs, justify classifying this as a high-stakes situation.


Medical Specialty: Radiology
Sample Name: Ultrasound OB - 1

EXAM: , OB Ultrasound.,HISTORY:,  A 29-year-old female requests for size and date of pregnancy.,FINDINGS: , A single live intrauterine gestation in the cephalic presentation, fetal heart rate is measured 147 beats per minute.  Placenta is located posteriorly, grade 0 without previa.  Cervical length is 4.2 cm.  There is normal amniotic fluid index of 12.2 cm.  There is a 4-chamber heart.  There is spontaneous body/limb motion.  The stomach, bladder, kidneys, cerebral ventricles, heel, spine, extremities, and umbilical cord are unremarkable.,BIOMETRIC DATA:,BPD = 7.77 cm = 31 weeks, 1 day,HC = 28.26 cm = 31 weeks, 1 day,AC = 26.63 cm = 30 weeks, 5 days,FL = 6.06 cm = 31 weeks, 4 days,Composite sonographic age 30 weeks 6 days plus minus 17 days.,ESTIMATED DATE OF DELIVERY: , Month DD, YYYY.,Estimated fetal weight is 3 pounds 11 ounces plus or minus 10 ounces.,IMPRESSION: , Single live intrauterine gestation without complications as described.
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DESCRIPTION: OB Ultrasound - A 29-year-old female requests for size and date of pregnancy.

radiology, ultrasound, ac, bpd, cervical length, estimated date of delivery, fl, hc, placenta, single live, amniotic fluid, bladder, cephalic, cephalic presentation, cerebral ventricles, extremities, fetal heart rate, fetal weight, gestation, heel, intrauterine, kidneys, pregnancy, previa, spine, stomach, umbilical cord, live intrauterine, intrauterine gestation

The situation involves an obstetric ultrasound assessing the gestational age, fetal position, and health status in a routine prenatal setting. While prenatal care is important for monitoring pregnancy health, this situation doesn’t indicate any complicating factors or emergent medical conditions, given the impression states 'without complications as described'. Thus, it suggests standard monitoring without immediate high-stakes medical decisions.


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

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

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

The procedure described is an open carpal tunnel release, which is a common surgical treatment for carpal tunnel syndrome. This is a routine procedure with a low risk of complications, and the report confirms that no complications occurred. The stakes in terms of risk and potential harm are relatively low compared to more complex surgeries that could affect vital organs or have life-threatening consequences.


Medical Specialty: Radiology
Sample Name: CT Chest - 2

CLINICAL HISTORY: , A 68-year-old white male with recently diagnosed adenocarcinoma by sputum cytology.  An abnormal chest radiograph shows right middle lobe infiltrate and collapse.  Patient needs staging CT of chest with contrast.  Right sided supraclavicular and lower anterior cervical adenopathy noted on physical exam.,TECHNIQUE: , Multiple transaxial images utilized in 10 mm sections were obtained through the chest.  Intravenous contrast was administered.,FINDINGS: , There is a large 3 x 4 cm lymph node seen in the right supraclavicular region.  There is a large right paratracheal lymph node best appreciated on image #16 which measures 3 x 2 cm.  A subcarinal lymph node is enlarged also.  It measures 6 x 2 cm.  Multiple pulmonary nodules are seen along the posterior border of the visceral as well as parietal pleura.  There is a pleural mass seen within the anterior sulcus of the right hemithorax as well as the right crus of the diaphragm.  There is also a soft tissue density best appreciated on image #36 adjacent to the inferior aspect of the right lobe of the liver which most likely also represents metastatic deposit.  The liver parenchyma is normal without evidence of any dominant masses.  The right kidney demonstrates a solitary cyst in the mid pole of the right kidney.,IMPRESSION:,1.  Greater than twenty pulmonary nodules demonstrated on the right side to include pulmonary nodules within the parietal as well as various visceral pleura with adjacent consolidation most likely representing pulmonary neoplasm.,2.  Extensive mediastinal adenopathy as described above.,3.  No lesion seen within the left lung at this time.,4.  Supraclavicular adenopathy.
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DESCRIPTION: A 68-year-old white male with recently diagnosed adenocarcinoma by sputum cytology.  An abnormal chest radiograph shows right middle lobe infiltrate and collapse.  Patient needs staging CT of chest with contrast.

radiology, supraclavicular, cervical adenopathy, pulmonary nodules, lymph node, adenopathy, pulmonary, chest,

The case involves a CT scan for a 68-year-old male recently diagnosed with adenocarcinoma, showing extensive metastatic spread, including nodules in the pleura, mediastinal adenopathy, and potential liver metastases. This suggests advanced cancer staging, which significantly impacts treatment decisions and prognosis. Therefore, it is a high-stakes situation as it directly affects the patient's treatment plan and outcome.


Medical Specialty: Radiology
Sample Name: MRI L-Spine - Subarachnoid Seeding

CC:, Progressive lower extremity weakness.,HX: ,This 52y/o RHF had a h/o right frontal glioblastoma multiforme (GBM) diagnosed by brain biopsy/partial resection, on 1/15/1991. She had been healthy until 1/6/91, when she experienced a generalized tonic-clonic type seizure during the night. She subsequently underwent an MRI brain scan and was found to have a right frontal enhancing lesion in the mesial aspect of the right frontal lobe at approximately the level of the coronal suture. There was minimal associated edema and no mass effect. Following extirpation of the tumor mass, she underwent radioactive Iodine implantation and 6020cGy radiation therapy in 35 fractions. In 11/91 she received BCNU and Procarbazine chemotherapy protocols. This was followed by four courses of 5FU/Carboplatin (3/92, 6/92, 9/92 ,10/92) chemotherapy.,On 10/12/92 she presented for her 4th course of 5FU/Carboplatin and complained of non-radiating dull low back pain, and proximal lower extremity weakness, but was still able to ambulate. She denied any bowel/bladder difficulty.,PMH: ,s/p oral surgery for wisdom tooth extraction.,FHX/SHX: ,1-2 ppd cigarettes. rare ETOH use. Father died of renal CA.,MEDS: ,Decadron 12mg/day.,EXAM: ,Vitals unremarkable.,MS: Unremarkable.,Motor: 5/5 BUE, LE: 4+/5- prox, 5/5 distal to hips. Normal tone and muscle bulk.,Sensory: No deficits appreciated.,Coord: Unremarkable.,Station: No mention in record of being tested.,Gait: Mild difficulty climbing stairs.,Reflexes: 1+/1+ throughout and symmetric. Plantar responses were down-going bilaterally.,INITIAL IMPRESSION:, Steroid myopathy. Though there was enough of a suspicion of "drop" metastasis that an MRI of the L-spine was obtained.,COURSE:, The MRI L-spine revealed fine linear enhancement along the dorsal aspect of the conus medullaris, suggestive of subarachnoid seeding of tumor. No focal mass or cord compression was visualized. CSF examination revealed: 19RBC, 22WBC, 17 Lymphocytes, and 5 histiocytes, Glucose 56, Protein 150. Cytology (negative). The patient was discharged home on 10/17/92, but experienced worsening back pain and lower extremity weakness and became predominantly wheelchair bound within 4 months. She was last seen on 3/3/93 and showed signs of worsening weakness (left hemiplegia: R > L) as her tumor grew and spread. She then entered a hospice.
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DESCRIPTION: MRI L-spine - History of progressive lower extremity weakness, right frontal glioblastoma with lumbar subarachnoid seeding.

radiology, glioblastoma multiforme, gbm, steroid myopathy, hemiplegia, progressive lower extremity weakness, mri l spine, lower extremity weakness, frontal glioblastoma, subarachnoid seeding, lower extremity, glioblastoma, subarachnoid, spine, mri, lower, weakness,

The situation involves a patient with a history of right frontal glioblastoma multiforme (GBM) who now presents with suspected subarachnoid seeding in the lumbar spine, resulting in progressive lower extremity weakness. The implications of detecting subarachnoid seeding include a significant change in prognosis, as it indicates the spread of cancer through the cerebrospinal fluid, which is associated with a poor outcome. This progression has led the patient to become predominantly wheelchair bound and to enter hospice care due to the growing and spreading tumor. The situation is high-stakes because it involves a severe, life-limiting condition with a rapidly declining health status, requiring significant interventions and consideration of end-of-life care.


Medical Specialty: General Medicine
Sample Name: Normal Female Exam Template - 1

PHYSICAL EXAMINATION,GENERAL:  ,The patient is awake and alert, in no apparent distress, appropriate, pleasant and cooperative.  No dysarthria is noted.  No discomfort on presentation is noted.,HEAD: , Atraumatic, normocephalic.  Pupils are equal, round and reactive to light.  Extraocular muscles are intact.  Sclerae are white without injection or icterus.  Fundi are without papilledema, hemorrhages or exudates with normal vessels.,EARS:  ,The ear canals are patent without edema, exudate or drainage.  Tympanic membranes are intact with a normal cone of light.  No bulging or erythema to indicate infection is present.  There is no hemotympanum.  Hearing is grossly intact.,NOSE: , Without deformity, bleeding or discharge.  No septal hematoma is noted.,ORAL CAVITY: , No swelling or abnormality to the lip or teeth.  Oral mucosa is pink and moist.  No swelling to the palate or pharynx.  Uvula is midline.  The pharynx is without exudate or erythema.  No edema is seen of the tonsils.  The airway is completely patent.  The voice is normal.  No stridor is heard.,NECK: , No signs of meningismus.  No Brudzinski or Kernig sign is present.  No adenopathy is noted.  No JVD is seen.  No bruits are auscultated.  Trachea is midline.,CHEST: , Symmetrical with equal breath sounds.  Equal excursion.  No hyperresonance or dullness to percussion is noted.  There is no tenderness on palpation of the chest.,LUNGS: , Clear to auscultation bilaterally.  No rales, rhonchi or wheezes are appreciated.  Good air movement is auscultated in all 4 lung fields.,HEART: , Regular rate and rhythm.  No murmur.  No S3, S4 or rub is auscultated.  Point of maximal impulse is strong and in normal position.  Abdominal aorta is not palpable.  The carotid upstroke is normal.,ABDOMEN: , Soft, nontender and nondistended.  Normal bowel sounds are auscultated.  No organomegaly is appreciated.  No masses are palpated.  No tympany is noted on percussion.  No guarding, rigidity or rebound tenderness is seen on exam.  Murphy and McBurney sign is negative.  There is no Rovsing, obturator or psoas sign present.  No hepatosplenomegaly and no hernias are noted.,RECTAL: , Normal tone.  No masses.  Soft, brown stool in the vault.  Guaiac negative.,GENITOURINARY: , External genitalia without erythema, exudate or discharge.  Vaginal vault is without discharge.  Cervix is of normal color without lesion.  The os is closed.  There is no bleeding noted.  Uterus is noted to be of normal size and nontender.  No cervical motion tenderness is seen.  No masses are palpated.  The adnexa are without masses or tenderness.,EXTREMITIES: , No clubbing, cyanosis or edema.  Pulses are strong and equal in the femoral and dorsalis pedis arteries, bounding and equal.  No deformity or signs of trauma.  All joints are stable without laxity.  There is good range of motion of all joints without tenderness or discomfort.  Homan sign is negative.  No atrophy or contractures are noted.,SKIN: , No rashes.  No jaundice.  Pink and warm with good turgor.  Good color.  No erythema or nodules noted.  No petechia, bulla or ecchymosis.,NEUROLOGIC: , Cranial nerves II through XII are grossly intact.  Muscle strength is graded 5/5 in the upper and lower extremities bilaterally.  Deep tendon reflexes are symmetrical in the upper and lower extremities bilaterally.  Babinski is downgoing bilaterally.  Sensation is intact to light touch and vibration.  Gait is normal.  Romberg, finger-to-nose, rapid alternating movements and heel-to-shin are all normal.  There is no ataxia seen on gait testing.  Tone is normal.  No pronator drift is seen.,PSYCHIATRIC:  ,The patient is oriented x4.  Mood and affect are appropriate.  Memory is intact with good short- and long-term memory recall.  No dysarthria is noted.  Remote memory is intact.  Judgment and insight appear normal.
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DESCRIPTION: An example/template for a routine normal female physical exam.

The provided medical examination template is an example of a routine physical exam for a female patient in general medicine. Such templates are commonly used by healthcare providers to ensure all necessary checks are comprehensively documented during a patient's visit, and these templates guide the systematic recording of normal findings in a healthy patient. The content does not indicate any urgency or immediate medical risk since it describes normal findings and standard procedural documentation.


Medical Specialty: Nephrology
Sample Name: AV Fistula - 5

PREOPERATIVE DIAGNOSES,1.  End-stage renal disease, hypertension, diabetes, need for chronic arteriovenous access.,2.  Ischemic cardiomyopathy, ejection fraction 20%.,POSTOPERATIVE DIAGNOSES,1.  End-stage renal disease, hypertension, diabetes, need for chronic arteriovenous access.,2.  Ischemic cardiomyopathy, ejection fraction 20%.,OPERATION,Left forearm arteriovenous fistula between cephalic vein and radial artery.,INDICATION FOR SURGERY,This is a patient referred by Dr. Michael Campbell.  He is a 44-year-old African-American, who has end-stage renal disease and also ischemic cardiomyopathy.  This morning, he received coronary angiogram by Dr. A, which was reportedly normal, after which, he was brought to the operating room for an AV fistula.  All the advantages, disadvantages, risks, and benefits of the procedure were explained to him for which he had consented.,ANESTHESIA,Monitored anesthesia care.,DESCRIPTION OF PROCEDURE,The patient was identified, brought to the operating room, placed supine, and IV sedation given.  This was done under monitored anesthesia care.  He was prepped and draped in the usual sterile fashion.  He received local infiltration of 0.25% Marcaine with epinephrine in the region of the proposed incision.,Incision was about 2.5 cm long between the cephalic vein and the distal part of the forearm and the radial artery.  Incision was deepened down through the subcutaneous fascia.  The vein was identified, dissected for a good length, and then the artery was identified and dissected.  Heparin 5000 units was given.  The artery clamped proximally and distally, opened up in the middle.  It was found to have Monckeberg's arteriosclerosis of a moderate intensity.  The vein was of good caliber and size.,The vein was clipped distally, fashioned to size and shape, and arteriotomy created in the distal radial artery and end-to-side anastomosis was performed using 7-0 Prolene and bled prior to tying it down.  Thrill was immediately felt and heard.,The incision was closed in two layers and sterile dressing applied.
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DESCRIPTION: Left forearm arteriovenous fistula between cephalic vein and radial artery.

nephrology, end-stage renal disease, av fistula, marcaine with epinephrine, monckeberg's, monitored anesthesia care, angiogram, arteriosclerosis, arteriovenous fistula, cephalic vein, ischemic cardiomyopathy, radial artery, subcutaneous fascia, arteriovenous, forearm, ischemic

The situation involves a surgical procedure, specifically the creation of an arteriovenous fistula for dialysis access in a patient with end-stage renal disease and ischemic cardiomyopathy. These medical conditions are serious and life-threatening, requiring surgical intervention to manage the patient's chronic kidney disease. The procedure itself, although common for patients needing dialysis, carries inherent risks such as bleeding, infection, or failure of the fistula. Additionally, the patient's existing comorbidities, such as severe heart disease indicated by a low ejection fraction, increase the stakes. The success of the procedure is crucial for the patient's ongoing dialysis and overall treatment plan.


Medical Specialty: Surgery
Sample Name: Cardiac Cath & Selective Coronary Angiography

PREOPERATIVE DIAGNOSIS: , Post infarct angina.,TYPE OF PROCEDURE: , Left cardiac catheterization with selective right and left coronary angiography.,PROCEDURE: , After informed consent was obtained, the patient was brought to the Cardiac Catheterization Laboratory, and the groin was prepped in the usual fashion.  Using 1% lidocaine, the right groin was infiltrated, and using the Seldinger technique, the right femoral artery was cannulated.  Through this, a moveable guidewire was then advance to the level of the diaphragm, and through it, a 6 French pigtail catheter was advanced under hemodynamic monitoring to the ascending aorta and inserted into the left ventricle.  Pressure measurements were obtained and cineangiograms in the RAO and LAO positions were then obtained.  Catheter was then withdrawn and a #6 French non-bleed-back sidearm sheath was then introduced, and through this, a 6 French Judkins left coronary catheter was then advanced under hemodynamic monitoring to the left coronary ostium, engaged.  Cineangiograms were obtained of the left coronary system.  This catheter was then exchanged for a Judkins right 4 coronary catheter of similar dimension and under hemodynamic monitoring again was advanced to the right coronary ostium, engaged.  Cineangiograms were obtained, and the catheter and sheath were then withdrawn.  The patient tolerated the procedure well and left the Cardiac Catheterization Laboratory in stable condition.  No evidence of hematoma formation or active bleeding.  ,COMPLICATIONS: , None.  ,TOTAL CONTRAST: , 110 cc of Hexabrix.  ,TOTAL FLUOROSCOPY TIME:  ,1.8 minutes.  ,MEDICATIONS: , Reglan 10 mg p.o., 5 mg p.o.  Valium, Benadryl 50 mg p.o. and heparin 3,000 units IV push.
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DESCRIPTION: Left cardiac catheterization with selective right and left coronary angiography.   Post infarct angina.

surgery, selective, angiography, post infarct angina, engaged cineangiograms, coronary angiography, hemodynamic monitoring, cardiac catheterization, catheterization, cineangiograms, cardiac, coronary,

The sample details a cardiac catheterization procedure, which is a medically significant and moderately invasive diagnostic or therapeutic procedure. The stakes are considered high because it involves the heart and significant blood vessels, with potential risks such as bleeding, hematoma, or other complications despite its frequent and routine nature in the clinical setting. However, the presence of informed consent, stable condition of the patient post-procedure, and absence of complications in this case slightly lower the stakes compared to more complex or emergency surgical interventions.


Medical Specialty: Surgery
Sample Name: Mini Laparotomy & Radical Retropubic Prostatectomy

PREOPERATIVE DIAGNOSIS:,  Adenocarcinoma of the prostate.,POSTOPERATIVE DIAGNOSIS:,  Adenocarcinoma of the prostate.,TITLE OF OPERATION:,  Mini-laparotomy radical retropubic prostatectomy with bilateral pelvic lymph node dissection with Cavermap.,ANESTHESIA: , General by intubation.,Informed consent was obtained for the procedure.  The patient understands the treatment options and wishes to proceed.  He accepts the risks to include bleeding requiring transfusion, infection, sepsis, incontinence, impotence, bladder neck constricture, heart attack, stroke, pulmonary emboli, phlebitis, injury to the bladder, rectum, or ureter, etcetera.,OPERATIVE PROCEDURE IN DETAIL: , The patient was taken to the Operating Room and placed in the supine position, prepped with Betadine solution and draped in the usual sterile fashion.  A 20- French Foley catheter was inserted into the penis and into the bladder and placed to dependent drainage.  The table was then placed in minimal flexed position.  A midline skin incision was then made from the umbilicus to the symphysis pubis.  It was carried down to the anterior rectus fascia into the pelvis proper.  Both obturator fossae were exposed.  Standard bilateral pelvic lymph node dissections were carried out.  The left side was approached first by myself.  The limits of my dissection were from the external iliac vein laterally to the obturator nerve medially, and from the bifurcation of the common iliac vein proximally to Cooper's ligament distally.  Meticulous lymphostasis and hemostasis was obtained using hemoclips and 2-0 silk ligatures.  The obturator nerve was visualized throughout and was not injured.  The right side was carried out by my assistant under my direct and constant supervision.  Again, the obturator nerve was visualized throughout and it was not injured.  Both packets were sent to Pathology where no evidence of carcinoma was found.,My attention was then directed to the prostate itself.  The  endopelvic fascia was opened bilaterally.  Using gentle dissection with a Kitner, I swept the levator muscles off the prostate and exposed the apical portion of the prostate.  A back bleeding control suture of 0 Vicryl was placed at the mid-prostate level.  A sternal wire was then placed behind the dorsal vein complex which was sharply transected.  The proximal and distal portions of this complex were then oversewn with 2-0 Vicryl in a running fashion.  When I was satisfied that hemostasis was complete, my attention was then turned to the neurovascular bundles.,The urethra was then sharply transected and six sutures of 2-0 Monocryl placed at the 1, 3, 5, 7, 9 and 11 o'clock positions.  The prostate was then lifted retrograde in the field and was swept from the anterior surface of the rectum and the posterior layer of Denonvilliers' fascia was incised distally, swept off the rectum and incorporated with the prostate specimen.  The lateral pedicles over the seminal vesicles were then mobilized, hemoclipped and transected.  The seminal vesicles themselves were then mobilized and hemostasis obtained using hemoclips.  Ampullae of the vas were mobilized, hemoclipped and transected.  The bladder neck was then developed using careful blunt and sharp dissection.  The prostate was then transected at the level of the bladder neck and sent for permanent specimen.  The bladder neck was reevaluated and the ureteral orifices were found to be placed well back from the edge.  The bladder neck was reconstructed in standard fashion.  It was closed using a running 2-0 Vicryl.  The mucosa was everted over the edge of the bladder neck using interrupted 3-0 Vicryl suture.  At the end of this portion of the case, the new bladder neck had a stoma-like appearance and would accommodate easily my small finger.  The field was then re-evaluated for hemostasis which was further obtained using hemoclips, Bovie apparatus and 3-0 chromic ligatures.  When I was satisfied that hemostasis was complete, the aforementioned Monocryl sutures were then placed at the corresponding positions in the bladder neck.  A new 20-French Foley catheter was brought in through the urethra into the bladder.  A safety suture of 0 Prolene was brought through the end of this and out through a separate stab wound in the bladder and through the left lateral quadrant.  The table was taken out of flexion and the bladder was then brought into approximation to the urethra and the Monocryl sutures were ligated.  The bladder was then copiously irrigated with sterile water and the anastomosis was found to be watertight.  The pelvis was also copiously irrigated with 2 liters of sterile water.  A 10-French Jackson-Pratt drain was placed in the pelvis and brought out through the right lower quadrant and sutured in place with a 2-0 silk ligature.,The wound was then closed in layers.  The muscle was closed with a running 0 chromic, the fascia with a running 1-0 Vicryl, the subcutaneous tissue with 3-0 plain, and the skin with a running 4-0 Vicryl subcuticular.  Steri-Strips were applied and a sterile dressing.,The patient was taken to the Recovery Room in good condition.  There were no complications.  Sponge and instrument counts were reported correct at the end of the case.
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DESCRIPTION: Mini-laparotomy radical retropubic prostatectomy with bilateral pelvic lymph node dissection with Cavermap.  Adenocarcinoma of the prostate.

surgery, mini-laparotomy, radical retropubic prostatectomy, pelvic lymph, pelvic lymph node dissection, cavermap, mini laparotomy, prostatectomy, bladder, intubation, adenocarcinoma, endopelvic, hemostasis, neck

This medical procedure involves a surgical operation for the removal of the prostate gland and nearby lymph nodes to treat prostate cancer, which is a serious medical condition. The risk factors associated with the surgery—such as bleeding, infection, sepsis, incontinence, impotence, and potential injury to nearby organs—indicate a high-stakes environment. The detailed post-operative report suggests a thorough and complex surgical process. Additionally, the operation involves the use of general anesthesia and a variety of surgical techniques to ensure the cancer is thoroughly removed, highlighting the procedure's complexity and necessity. Given these factors, the stakes are high due to the potential risks and the nature of cancer surgery.


Medical Specialty: Neurosurgery
Sample Name: Anterior Cervical Discectomy & Fusion - 7

PREOPERATIVE DIAGNOSIS:,  C4-C5, C5-C6 stenosis.,PREOPERATIVE DIAGNOSIS: , C4-C5, C5-C6 stenosis.,PROCEDURE: , C4-C5, C5-C6 anterior cervical discectomy and fusion.,COMPLICATIONS: , None.,ANESTHESIA: , General.,INDICATIONS OF PROCEDURE: , The patient is a 62-year-old female who presents with neck pain as well as upper extremity symptoms.  Her MRI showed stenosis at portion of C4 to C6.  I discussed the procedure as well as risks and complications.  She wishes to proceed with surgery.  Risks will include but are not limited to infection, hemorrhage, spinal fluid leak, worsened neurologic deficit, recurrent stenosis, requiring further surgery, difficulty with fusion requiring further surgery, long-term hoarseness of voice, difficulty swallowing, medical anesthesia risk.,PROCEDURE:  ,The patient was taken to the operating room on 10/02/2007.  She was intubated for anesthesia.  TEDS and boots as well as Foley catheter were placed.  She was placed in a supine position with her neck in neutral position.  Appropriate pads were also used.  The area was prepped and draped in usual sterile fashion.  Preoperative localization was taken.  _____ not changed.  Incision was made on the right side in transverse fashion over C5 vertebral body level.  This was made with a #10 blade knife and further taken down with pickups and scissors.  The plane between the esophagus and carotid artery was carefully dissected both bluntly and sharply down to the anterior aspect of the cervical spine.  Intraoperative x-ray was taken.  Longus colli muscles were retracted laterally.  Caspar retractors were used.  Intraoperative x-ray was taken.  I first turned by attention at C5-C6 interspace.  This was opened with #15 blade knife.  Disc material was taken out using pituitary as well as Kerrison rongeur.  Anterior aspects were taken down.  End plates were arthrodesed using curettes.  This was done under distraction.  Posterior longitudinal ligament was opened with a nerve hook and Kerrison rongeur.  Bilateral foraminotomies were done.  At this point, I felt that there was a good decompression.  The foramen appeared to be opened.  Medtronic cage was then encountered and sent few millimeters.  This was packed with demineralized bone matrix.  The distraction was then taken down.  The cage appeared to be strong.  This procedure was then repeated at C4-C5.  A 42-mm AcuFix plate was then placed between C4 and C6.  This was carefully screwed and locked.  The instrumentation appeared to be strong.  Intraoperative x-ray was taken.  Irrigation was used.  Hemostasis was achieved.  The platysmas was closed with 3-0 Vicryl stitches.  The subcutaneous was closed with 4-0 Vicryl stitches.  The skin was closed with Steri-strips.  The area was clean and dry and dressed with Telfa and Tegaderm.  Soft cervical collar was placed for the patient.  She was extubated per anesthesia and brought to the recovery in stable condition.
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DESCRIPTION: C4-C5, C5-C6 anterior cervical discectomy and fusion.  The patient is a 62-year-old female who presents with neck pain as well as upper extremity symptoms.  Her MRI showed stenosis at portion of C4 to C6.

neurosurgery, anterior cervical discectomy, fusion, infection, hemorrhage, spinal fluid leak, anesthesia, foley catheter, teds, anterior cervical, cervical discectomy, anterior, cervical, discectomy, stenosis,

The scenario involves a neurosurgical procedure, specifically an anterior cervical discectomy and fusion, which is a complex surgery of the spine. Given the nature of this procedure, it inherently involves high risks such as infection, bleeding, nerve damage, and potential complications from general anesthesia. Additionally, any error during the surgery could have significant repercussions on the patient's health, including worsened neurological conditions or the need for further surgeries. Therefore, the stakes in this context are quite high.


Medical Specialty: Orthopedic
Sample Name: Hand Pain - Consult

REASON FOR VISIT:  ,New patient visit for right hand pain.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 28-year-old right-hand dominant gentleman, who punched the wall 3 days prior to presentation.  He complained of ulnar-sided right hand pain and was seen in the emergency room.  Reportedly, he had some joints in his hand pushed back and placed by somebody in emergency room.  Today, he admits that his pain is much better.  Currently, since that time he has been in the splint with minimal pain.  He has had no numbness, tingling or other concerning symptoms.,PAST MEDICAL HISTORY:, Negative.,SOCIAL HISTORY:  ,The patient is a nonsmoker and does not use illegal drugs.  Occasionally drinks.,REVIEW OF SYSTEMS: , A 12-point review of systems is negative.,MEDICATIONS:,  None.,ALLERGIES: , No known drug allergies.,FINDINGS: , On physical exam, he has swelling and tenderness over the ulnar dorsum of his hand.  He has a normal cascade.  He has 70 degrees of MCP flexion and full IP flexion and extension.  He has 3 to 5 strength in his grip and intrinsics.  He has intact sensation to light touch in the radial, ulnar, and median nerve distribution.  Two plus radial pulse.,X-rays taken from today were reviewed, include three views of the right hand.  They show possible small fractures of the base of the fourth and third metacarpals.  Joint appears to be located.  A 45-degree oblique view was obtained and confirmed adduction of the CMC joints of the fourth and fifth metacarpals.  His injury films from 09/15/07 were reviewed and demonstrated what appears to be CMC dislocations of the third and fourth metacarpals.,ASSESSMENT: , Status post right third and fourth metacarpal carpometacarpal dislocations.,PLANS: , The patient was placed into a short-arm cast and intrinsic plus.  I would like him to wear this for 2 weeks and then follow up with us.  At that time, we will transition him to an OT splint and begin range of motion activities of the fingers and wrist.  We should see him back in 2 weeks' time at which time he should obtain three views of the right hand and a 45-degree oblique view out of cast.
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DESCRIPTION: New patient visit for right hand pain.  Punched the wall 3 days prior to presentation, complained of ulnar-sided right hand pain, and was seen in the emergency room.

orthopedic, hand pain, pain, hand, metacarpals

The situation involves a new patient with a hand injury following an altercation with a wall. While hand injuries can affect quality of life and functionality, the patient shows improvement in pain levels and no concerning symptoms like numbness or tingling. The treatment plan is straightforward with a short-arm cast and scheduled follow-ups. This is a typical orthopedic case and does not suggest a life-threatening or severely debilitating situation.


Medical Specialty: Neurosurgery
Sample Name: Lumbar Puncture - 1

PROCEDURE: , Lumbar puncture with moderate sedation.,INDICATION: , The patient is a 2-year, 2-month-old little girl who presented to the hospital with severe anemia, hemoglobin 5.8, elevated total bilirubin consistent with hemolysis and weak positive direct Coombs test.  She was transfused with packed red blood cells.  Her hemolysis seemed to slow down.  She also on presentation had indications of urinary tract infection with urinalysis significant for 2+ leukocytes, positive nitrites, 3+ protein, 3+ blood, 25 to 100 white cells, 10 to 25 bacteria, 10 to 25 epithelial cells on clean catch specimen.  Culture subsequently grew out no organisms; however, the child had been pretreated with amoxicillin about x3 doses prior to presentation to the hospital.  She had a blood culture, which was also negative.  She was empirically started on presentation with the cefotaxime intravenously.  Her white count on presentation was significantly elevated at 20,800, subsequently increased to 24.7 and then decreased to 16.6 while on antibiotics.  After antibiotics were discontinued, she increased over the next 2 days to an elevated white count of 31,000 with significant bandemia, metamyelocytes and myelocytes present.  She also had three episodes of vomiting and thus she is being taken to the procedure room today for a lumbar puncture to rule out meningitis that may being inadvertently treated in treating her UTI.,I discussed with The patient's parents prior to the procedure the lumbar puncture and moderate sedation procedures.  The risks, benefits, alternatives, complications including, but not limited to bleeding, infection, respiratory depression.  Questions were answered to their satisfaction.  They would like to proceed.,PROCEDURE IN DETAIL: , After "time out" procedure was obtained, the child was given appropriate monitoring equipment including appropriate vital signs were obtained.  She was then given Versed 1 mg intravenously by myself.  She subsequently became sleepy, the respiratory monitors, end-tidal, cardiopulmonary and pulse oximetry were applied.  She was then given 20 mcg of fentanyl intravenously by myself.  She was placed in the left lateral decubitus position.  Dr. X cleansed the patient's back in a normal sterile fashion with Betadine solution.  She inserted a 22-gauge x 1.5-inch spinal needle in the patient's L3-L4 interspace that was carefully identified under my direct supervision.  Clear fluid was not obtained initially, needle was withdrawn intact.  The patient was slightly repositioned by the nurse and Dr. X reinserted the needle in the L3-L4 interspace position, the needle was able to obtain clear fluid, approximately 3 mL was obtained.  The stylette was replaced and the needle was withdrawn intact and bandage was applied.  Betadine solution was cleansed from the patient's back.,During the procedure, there were no untoward complications, the end-tidal CO2, pulse oximetry, and other vitals remained stable.  Of note, EMLA cream had also been applied prior procedure, this was removed prior to cleansing of the back.,Fluid will be sent for a routine cell count, Gram stain culture, protein, and glucose.,DISPOSITION: , The child returned to room on the medical floor in satisfactory condition.
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DESCRIPTION: Lumbar puncture with moderate sedation.

Lumbar puncture with moderate sedation.

neurosurgery, moderate sedation, lumbar puncture, needle, lumbar,

The situation involves a lumbar puncture procedure on a young child with multiple underlying medical concerns including a suspected meningitis and severe anemia. The procedure has potential risks such as bleeding, infection, and respiratory depression. Additionally, the child requires sedation which adds further complexity and risk. Overall, this medical procedure is high-stakes due to the potential complications and the critical condition of the patient.


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

Medical Specialty: Surgery
Sample Name: Foreign Body Removal - Thigh

PREPROCEDURE DIAGNOSIS:,  Foreign body of the right thigh.,POSTOPERATIVE DIAGNOSIS: , Foreign body of the right thigh, sewing needle.,PROCEDURE:  ,Removal of foreign body of right thigh.,HISTORY:  ,This is a 71-year-old lady who has been referred because there is a mass in the right thigh.  The patient comes with an ultrasound and apparently was diagnosed with a blood clot.  On physical examination, blood pressure was 152/76 and temperature was 95.0.  The patient is 5 feet 1 inch and weighs 170.  On examination of her right thigh, there is a transverse area of ecchymosis in the upper third of the thigh.  There is a palpation of a very sharp object just under the skin.  The patient desires for this to be removed.,DESCRIPTION OF PROCEDURE: , After obtaining informed consent in our office, the area was prepped and draped in usual fashion.  Xylocaine 1% was infiltrated in the end of the object that was the sharpest and a small incision was made there and then I pushed the foreign body through partially and then grabbed it with a hemostat and took it out and it was a 1-1/2-inch sewing needle.,Compression was applied for a few minutes and then a Band-Aid was applied.,The patient was given a tetanus toxoid 0.5 cc IM shot injection and then she was dismissed with instructions of return if inflammatory signs develop.
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DESCRIPTION: Removal of foreign body of right thigh.  Foreign body of the right thigh, sewing needle.

surgery, removal of foreign body, sewing needle, foreign body

The procedure involves removing a foreign body, specifically a sewing needle, from the thigh of a 71-year-old patient. While any surgical procedure carries inherent risks, this one is relatively straightforward. It is not an emergency, as indicated by the pre-procedure preparation, including obtaining informed consent and the patient being dismissed with standard aftercare instructions. There are no immediate life-threatening conditions or complex medical issues resulting from the presence of the needle, aside from potential inflammation or infection which are standard risks manageable with proper care. Therefore, the situation is not high-stakes.


Medical Specialty: Gastroenterology
Sample Name: Colonoscopy - 17

PREOPERATIVE DIAGNOSIS: , Colon polyps.,POSTOPERATIVE DIAGNOSES:,1.  Universal diverticulosis.,2.  Nonsurgical internal hemorrhoids.,PROCEDURE PERFORMED:, Total colonoscopy with photos.,ANESTHESIA:,  Demerol 100 mg IV with Versed 3 mg IV.,SPECIMENS: , None.,ESTIMATED BLOOD LOSS: , Minimal.,INDICATIONS FOR PROCEDURE:  ,The patient is a 62-year-old white male who presents to the office with a history of colon polyps and need for recheck.,PROCEDURE:,  Informed consent was obtained.  All risks and benefits of the procedure were explained and all questions were answered.  The patient was brought back to the Endoscopy Suite where he was connected to cardiopulmonary monitoring.  Demerol 100 mg IV and Versed 3 mg IV was given in a titrated fashion until appropriate anesthesia was obtained.  Upon appropriate anesthesia, a digital rectal exam was performed, which showed no masses.  The colonoscope was then placed into the anus and the air was insufflated.  The scope was then advanced under direct vision into the rectum, rectosigmoid colon, descending colon, transverse colon, ascending colon until it reached the cecum.  Upon entering the sigmoid colon and throughout the rest of the colon, there was noted diverticulosis.  After reaching the cecum, the scope was fully withdrawn visualizing all walls again noting universal diverticulosis.,Upon reaching the rectum, the scope was then retroflexed upon itself and there was noted to be nonsurgical internal hemorrhoids.  The scope was then subsequently removed.  The patient tolerated the procedure well and there were no complications.
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DESCRIPTION: Universal diverticulosis and nonsurgical internal hemorrhoids. Total colonoscopy with photos.  The patient is a 62-year-old white male who presents to the office with a history of colon polyps and need for recheck.

gastroenterology, endoscopy, rectum, rectosigmoid colon, descending colon, transverse colon, ascending colon, total colonoscopy, colon polyps, colonoscopy, cecum, polyps, diverticulosis, hemorrhoids,

The procedure described is a standard colonoscopy, which is a routine, low-risk procedure often performed for screening or surveillance of colon health, especially in patients with a history of colon polyps. The report indicates that the procedure went smoothly, with minimal blood loss and no complications. The findings of universal diverticulosis and nonsurgical internal hemorrhoids are common and typically not immediately life-threatening. Given the context, this is a low-stakes situation.


Medical Specialty: Surgery
Sample Name: Bronchoscopy - 5

PREOPERATIVE DIAGNOSIS:,  Airway stenosis with self-expanding metallic stent complication.,POSTOPERATIVE DIAGNOSIS:,  Airway stenosis with self-expanding metallic stent complication.,PROCEDURES:,1.  Rigid bronchoscopy with removal of foreign body, prolonged procedure taking two hours to remove the stent piecemeal in a very difficult and trying situation.,2.  Excision of granulation tissue tumor.,3.  Bronchial dilation with a balloon bronchoplasty, right main bronchus.,4.  Argon plasma coagulation to control bleeding in the trachea.,5.  Placement of a tracheal and bilateral bronchial stents with a silicon wire stent.,ENDOSCOPIC FINDINGS:,1.  Normal true vocal cords.,2.  Proximal trachea with high-grade occlusion blocking approximately 90% of the trachea due to granulation tissue tumor and break down of metallic stent.,3.  Multiple stent fractures in the mid portion of the trachea with granulation tissue.,4.  High-grade obstruction of the right main bronchus by stent and granulation tissue.,5.  Left main bronchus was covered by the distal portion of the stent and was only being ventilated through the struts of the stent.,6.  All in all a high-grade terrible airway obstruction with involvement of the carina, left and right main stem bronchus, mid, distal, and proximal trachea.,TECHNIQUE IN DETAIL: , After informed consent was obtained from the patient, he was brought into the operating field.  A rapid sequence induction was done.  He was intubated with a rigid scope.  Jet ventilation technique was carried out using a rigid and flexible scope.  A thorough airway inspection was carried out with findings as described above.,Dr. D was present in the operating room and we conferred on operative strategy and agreed that the best of strategy would be to first dilate the right main bronchus, cauterize it to control bleeding and then piecemeal removed the stent from distal to proximal.  This is the technique that was carried out in a painstaking fashion removing bits of the stent piecemeal with finally getting all of the visible stent out of the airway.  It should be noted that Dr. Donovan and I felt that two of the metallic stents were probably in place but we cannot be sure because of the terrible anatomy and the fact that the stent pieces were coming out twisted metal in fragments.  Nevertheless, all the visible stent was removed, and the airway was much better after with the dilation of balloon and the rigid scope.  We took measurements and decided to place stents in the trachea, left and right main bronchus using a Dumon Y-stent.  It was measured 18 mm in tracheal diameter and 14 mm in bronchial diameter.  The right main stem stent was 2.25 cm in length, the left main stem stent was 3 cm in length and the tracheal portion was 9 cm in length.  After it was placed, excellent placement was achieved with the proximal end of the stent 3 cm below the true vocal cords.  The patient tolerated the procedure well and was brought to the recovery room extubated.
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DESCRIPTION: Rigid bronchoscopy, removal of foreign body, excision of granulation tissue tumor, bronchial dilation , Argon plasma coagulation, placement of a tracheal and bilateral bronchial stents.

surgery, airway, argon plasma coagulation, bronchial dilation, balloon bronchoplasty, bronchoscopy, bronchus, foreign body, granulation, metallic stent, stenosis, vocal cords, granulation tissue tumor, plasma coagulation, granulation tissue, tracheal, argon, stents, bronchial, metallic,

The situation described is high-stakes due to several factors. The patient's airway had a high-grade obstruction, blocking 90% of the trachea, which is life-threatening as it can severely impair breathing. The procedure involved complex and risky operations such as removing a stent piece by piece, excision of tissue, bronchial dilation, and controlling bleeding, all vital to ensuring the patient can breathe properly again. The involvement of multiple medical techniques highlights the complexity and critical nature of the scenario, emphasizing its high-stakes nature.


Medical Specialty: Neurosurgery
Sample Name: Shunt Revision - 1

PREOPERATIVE DIAGNOSIS: , Shunt malfunction.  The patient with a ventriculoatrial shunt.,POSTOPERATIVE DIAGNOSIS:,  Shunt malfunction.  The patient with a ventriculoatrial shunt.,ANESTHESIA: , General endotracheal tube anesthesia.,INDICATIONS FOR OPERATION: , Headaches, fluid accumulating along shunt tract.,FINDINGS: , Partial proximal shunt obstruction.,TITLE OF OPERATION:,  Endoscopic proximal shunt revision.,SPECIMENS: , None.,COMPLICATIONS:,  None.,DEVICES: , Portnoy ventricular catheter.,OPERATIVE PROCEDURE:,  After satisfactory general endotracheal tube anesthesia was administered, the patient positioned on the operating table in supine position with the right frontal area shaved and the head was prepped and draped in a routine manner.  The old right frontal scalp incision was reopened in a curvilinear manner, and the Bactiseal ventricular catheter was identified as it went into the right frontal horn.  The distal end of the VA shunt was flushed and tested with heparinized saline, found to be patent, and it was then clamped.  Endoscopically, the proximal end was explored and we found debris within the lumen, and then we were able to freely move the catheter around.  We could see along the tract that the tip of the catheter had gone into the surrounding tissue and appeared to have prongs or extensions in the tract, which were going into the catheter consistent with partial proximal obstruction.  A Portnoy ventricular catheter was endoscopically introduced and then the endoscope was bend so that the catheter tip did not go into the same location where it was before, but would take a gentle curve going into the right lateral ventricle.  It flushed in quite well, was left at about 6.5 cm to 7 cm and connected to the existing straight connector and secured with 2-0 Ethibond sutures.  The wounds were irrigated out with Bacitracin and closed in a routine manner using two 3-0 Vicryl for the galea and a 4-0 running Monocryl for the scalp followed by Mastisol and Steri-Strips.  The patient was awakened and extubated having tolerated the procedure well without complications.  It should be noted that the when we were irrigating through the ventricular catheter, fluid easily came out around the catheter indicating that the patient had partial proximal obstruction so that we could probably flow around the old shunt tract and perhaps this was leading to some of the symptomatology or findings of fluid along the chest.
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DESCRIPTION: Endoscopic proximal shunt revision.

Endoscopic proximal shunt revision.

neurosurgery, ventriculoatrial shunt, endoscopic proximal shunt revision, endoscopic proximal shunt, portnoy ventricular catheter, shunt malfunction, shunt revision, ventricular catheter, shunt, endoscopic, ventricular, proximal, catheter,

The scenario involves a neurosurgical procedure to address a shunt malfunction, which is a critical medical condition. Shunt malfunctions can lead to serious complications like increased intracranial pressure, headaches, and fluid accumulation. The procedure described, an endoscopic proximal shunt revision, requires precise surgical intervention, and even though it was performed successfully without complications, the nature of neurosurgery and the potential risks involved mark it as high-stakes. Ensuring proper function of the ventricular shunt is crucial for the patient's health and well-being.


Medical Specialty: Surgery
Sample Name: Heart Catheterization & Angiography - 2

PROCEDURES PERFORMED:,1.  Left heart catheterization.,2.  Bilateral selective coronary angiography.,3.  Left ventriculogram was not performed.,INDICATION: , Non-ST elevation MI.,PROCEDURE: , After risks, benefits, and alternatives of the above-mentioned procedure were explained in detail to the patient, informed consent was obtained both verbally and in writing.  The patient was taken to cardiac catheterization suite where the right femoral region was prepped and draped in the usual sterile fashion.  1% lidocaine solution was used to infiltrate the skin overlying the right femoral artery.  Once adequate anesthesia had been obtained, a thin-walled #18 gauge Argon needle was used to cannulate the right femoral artery.  A steel guidewire was inserted through the needle into the vascular lumen without resistance.  A small nick was then made in the skin.  The pressure was held.  The needle was removed over the guidewire.  Next, a Judkins left #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire.  The guidewire was removed.  The catheter was connected to the manifold and flushed.  The ostium of the left main coronary artery was engaged.  Using hand injections of nonionic contrast material, the left coronary system was evaluated in several different views.  Once an adequate study had been performed, the catheter was removed from the ostium of the left main coronary artery and a steel guidewire was inserted through the catheter.  The catheter was then removed over the guidewire.,Next, a Judkins right #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire.  The guidewire was removed.  The catheter was connected to manifold and flushed.  The catheter did slip into the left ventricle.  During the rotation, the LVEDP was then measured.  The ostium of the right coronary artery was then engaged.  Using hand injections of nonionic contrast material, the right coronary system was evaluated in several different views.  Once adequate study has been performed, the catheter was then removed.  The sheath was lastly flushed for the final time.,FINDINGS:,LEFT MAIN CORONARY ARTERY: , The left main coronary artery is a moderate caliber vessel, which bifurcates into the left anterior descending and circumflex arteries.  There is no evidence of any hemodynamically significant stenosis.,LEFT ANTERIOR DESCENDING ARTERY: , The LAD is a moderate caliber vessel, which is subtotaled in its mid portion for approximately 1.5 cm to 1 cm with subsequent TIMI-I flow distally.  The distal portion was diffusely diseased.  The proximal portion otherwise shows minor luminal irregularities.  The first diagonal branch demonstrated minor luminal irregularities throughout.,CIRCUMFLEX ARTERY:  ,The circumflex is a moderate caliber vessel, which traverses through the atrioventricular groove.  There is a 60% proximal lesion and a 90% mid lesion prior to the takeoff of the first obtuse marginal branch.  The first obtuse marginal branch demonstrates minor luminal irregularities throughout.,RIGHT CORONARY ARTERY: , The RCA is a moderate caliber vessel, which demonstrates a 90% mid stenotic lesion.  The dominant coronary artery gives off the posterior descending artery and posterolateral artery.  The left ventricular end-diastolic pressure was approximately 22 mmHg.  It should be noted that during injection of the contrast agent that there was ST elevation in the inferior leads, which resolved after the injection was complete.,IMPRESSION:,1.  Three-vessel coronary artery disease involving a subtotaled left anterior descending artery with TIMI-I flow distally and 90% circumflex lesion and 90% right coronary artery lesion.,2.  Mildly elevated left-sided filling pressures.,PLAN:,1.  The patient will be transferred to Providence Hospital today for likely PCI of the mid LAD lesion with a surgical evaluation for a coronary artery bypass grafting.  These findings and plan were discussed in detail with the patient and the patient's family.  The patient is agreeable.,2.  The patient will be continued on aggressive medical therapy including beta-blocker, aspirin, ACE inhibitor, and statin therapy.  The patient will not be placed on Plavix secondary to the possibility for coronary bypass grafting.  In light of the patient's history of cranial aneurysmal bleed, the patient will be held off of Lovenox and Integrilin.
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DESCRIPTION: Left heart catheterization and bilateral selective coronary angiography. Left ventriculogram was not performed.

surgery, non-st elevation, coronary angiography, ventriculogram, heart catheterization, bypass grafting, catheterization, coronary, artery, angiography, luminal, branch, descending, circumflex, vessel, guidewire,

The procedure described is a heart catheterization and angiography, which are significant medical procedures commonly used to diagnose and treat heart conditions. The patient has a serious condition, indicated by a non-ST elevation myocardial infarction (MI) and significant coronary artery disease affecting multiple vessels. These conditions can lead to life-threatening complications if not treated appropriately. The plan involves potential PCI (Percutaneous Coronary Intervention) and surgical evaluation for a coronary artery bypass grafting, indicating the high stakes involved in managing the patient's condition to prevent more severe outcomes like heart attack or heart failure.


Medical Specialty: Urology
Sample Name: Penile Injury

REASON FOR ADMISSION:,  Penile injury and continuous bleeding from a penile laceration.,HISTORY OF PRESENT ILLNESS:,  The patient is an 18-year-old detainee who was brought by police officers because of a penile injury and bleeding.  He is otherwise healthy.  He tried to insert a marble in his penis four days ago.  He told me that he grabbed the skin on the top of the penis and moved it away from the penis shaft and then using a toothbrush that he made in to a knife object he pierced the skin through from both sides and then kept moving the toothbrush to dilate and make a way for the marble.  Then he inserted a heart-shaped marble in one of the puncture wounds and inserted it under the skin and kept it there.  He was not significantly bleeding and essentially the bleeding stopped from both puncture wounds that he has.  Then today four days after that procedure, he was taking a bath today and he thinks because of the weight he felt a gush in his pants and he looked and he saw the bleeding come out.  He was bleeding so much that he started dripping to the sides of his legs.  So, he was brought to the hospital.  Actually after being seen by two nurses at the facility where he was at the detention center where he was at and they actually did the dressing twice and it was twice soaked with blood.  He came here and was continuously bleeding from that area that we had to change the dressing twice and he is actually still bleeding especially from one of the laceration, the one on the right side of the penis.  The marble also still can be felt underneath the skin.  There is no urethral bleeding.  He did urinate today without difficulty, without hematuria or dysuria.  There is pain in the lacerations.  No erythema in the skin or swelling in the penis and no other injuries.  He did this procedure for sexual pleasure as he said.,PAST MEDICAL HISTORY: , Unremarkable.,PAST SURGICAL HISTORY:  ,Tonsillectomy.,MEDICATION: , He took only ibuprofen.  No regular medication.,ALLERGIES: , None.,SOCIAL HISTORY:  ,He has been in detention for two months for immigration problems.  No drugs.  No alcohol.  No smoking.  He used to work in fast food chain.,FAMILY HISTORY: , Noncontributory to this illness.,REVIEW OF SYSTEMS: , Aside from the pain in the penis and continuous bleeding, he is basically asymptomatic and review of systems is unremarkable.,PHYSICAL EXAMINATION:,GENERAL:  The patient is a young Hispanic male, lying in bed, appear comfortable in no apparent distress.,VITAL SIGNS:  Temperature 97.8, heart rate 99, respiratory rate 20, blood pressure 142/100, and saturation is 98% on room air.,ENT:  Sclerae nonicteric.  Pupils reactive to light.  Nostrils are normal.  Oral cavity is clear.,NECK:  Supple.  Trachea midline.  No JVD.,LUNGS:  Clear to auscultation bilaterally.,HEART:  Normal S1 and S2.  No murmurs or gallops.,ABDOMEN:  Soft, nontender, and nondistended.  Positive bowel sounds.,EXTREMITIES:  Pulses strong bilaterally.  No edema.,GENITAL:  Testicles appear normal.  The penis shaft has two lacerations on both sides, one of them is bleeding.  They measure about 5 to 6 mm on the right side, about 3 or 4 mm on the left side.  The one on the right side is bleeding much more than the other one.  There is a marble that can be felt and it is freely mobile underneath the skin of the dorsum of the penis.  There is no bleeding from the meatus or discharge and no other injuries were seen by inspection.,LABORATORY DATA:,  White count 11.1, hemoglobin 14.5, hematocrit 43.5, and platelets 303,000.  Coags unremarkable.  Glucose 106, creatinine 0.8, sodium 141, potassium 4, and calcium 9.7.  Urinalysis unremarkable.,IMPRESSION: , The patient with a penile laceration that is continuously bleeding from inserting a marble four days ago, which is still underneath the skin of the shaft of the penis.  No other injuries that can be seen and no other evidence of secondary bacterial infection at this time.  The patient is currently refusing removal of the marble and insisting on just repairing the laceration and he is having discussion with Dr. X.,PLAN:,1.  The patient will be admitted to the hospital and will follow Dr. X's recommendation.,2.  The patient was offered a repair of those lacerations, to stop the bleeding as well as the removal of the marble and he is currently considering that and discussing that with Dr. X.,3.  Prophylactic antibiotics to prevent infection.,4.  He has mild hypertension, which is likely due to stress and pain and also the leukocytosis probably can be explained by that.  This will be monitored.,5.  Monitor H&H to determine if he needs any transfusion at this time.  He does not need that.,6.  IV fluid for hydration and volume resuscitation at this time.,7.  Pain management.,8.  Topical care for the wound VAC after repair.,Time spent in evaluation and management of this patient including discussions about this procedure and the harm that can happen if he chooses to keep the penis including permanent damage and infection to the penis was 65 minutes.,I had clearly explained to the patient in detail about the possibility of permanent penile damage that could affect erection and future sexual functioning as well as significant infection if a foreign object was retained in the penis under the skin and he verbalized understanding of this.
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DESCRIPTION: Penile injury and continuous bleeding from a penile laceration.

The situation involves an 18-year-old patient with a penile injury that is continuously bleeding due to self-infliction. This case is high-stakes due to several factors: there is active bleeding which can lead to significant blood loss, there is a foreign object retained which poses a risk of infection, and there is the potential for permanent damage to the penile tissue, which can affect future sexual function. Despite these factors, the patient is refusing immediate removal of the foreign object, complicating medical intervention and necessitating discussions about the potential for serious complications. This combination of medical urgency and the patient's current decision-making raises the stakes substantially.


Medical Specialty: General Medicine
Sample Name: Gen Med Consult - 21

SUBJECTIVE:,  The patient is a 2-year-old little girl who comes in with concerns about stuffiness, congestion and nasal drainage.  She does take Zyrtec on a fairly regular basis.  Mom is having some allergy trouble herself right now.  She does not know her colors.  She knows some of her shapes.  She speaks in sentences.  She is not showing much interest in the potty.  She is in the 80th percentile for height and weight, and still over 95th percentile for head circumference.  Mom has no other concerns.,ALLERGIES:,  Eggs and peanuts.,OBJECTIVE:,General:  Alert, very talkative little girl.,HEENT:  TMs clear and mobile.  Eyes:  PERRL.  Fundi benign.  Pharynx clear.  Mouth moist.  Nasal mucosa is pale with clear discharge.,Neck:  Supple without adenopathy.,Heart:  Regular rate and rhythm without murmur.,Lungs:  Clear.  No tachypnea, wheezing, rales or retractions.,Abdomen:  Soft and nontender without mass or organomegaly.,GU:  Normal female genitalia.  Tanner stage I.,Extremities:  No clubbing, cyanosis or edema.  Pulses 2+ and equal.,Hips:  Intact.,Neurological:  Normal.  DTRs are 2+.  Gait was normal.,Skin:  Warm and dry.  No rashes noted.,ASSESSMENT:,  Allergic rhinitis.  Otherwise healthy 2-year-old young lady.,PLAN:,  In addition to her Zyrtec, I put her on Nasonex spray one spray each nostril daily.  If this works for her, certainly she can do it through the ragweed season.  Otherwise she is doing well.  I talked about ways to improve her potty training.  She is a very good eater.  I will see her yearly or p.r.n.  Unfortunately she is not able to get the flu shot due to her egg allergy.
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DESCRIPTION: A 2-year-old little girl with stuffiness, congestion, and nasal drainage. - Allergic rhinitis

general medicine, allergic rhinitis, nasal drainage, stuffiness, congestion, drainage,

The situation involves a routine medical examination of a 2-year-old girl experiencing typical allergy symptoms that are being managed with medication. There are no indications of emergency or serious medical conditions. The case is well within the capabilities of general medical practice, and no immediate risks or severe health concerns are present. Furthermore, the patient is otherwise healthy and developing normally for her age.


Medical Specialty: Discharge Summary
Sample Name: Urology Discharge Summary

PROCEDURES:, Cystourethroscopy and transurethral resection of prostate.,COMPLICATIONS:, None.,ADMITTING DIAGNOSIS:, Difficulty voiding.,HISTORY:, This 67-year old Hispanic male patient was admitted because of enlarged prostate and symptoms of bladder neck obstruction.  Physical examination revealed normal heart and lungs.  Abdomen was negative for abnormal findings.  ,LABORATORY DATA:, BUN 19 and creatinine 1.1.  Blood group was A, Rh positive, Hemoglobin 13, Hematocrit 32.1, Prothrombin time 12.6 seconds, PTT 37.1.  Discharge  hemoglobin 11.4, and hematocrit 33.3.  Chest x-ray calcified old granulomatous disease, otherwise normal.  EKG was normal.  ,COURSE IN THE HOSPITAL:, The patient had a cysto and TUR of the prostate.  Postoperative course was uncomplicated. The pathology report is pending at the time of dictation.  He is being discharged in satisfactory condition with a good urinary stream, minimal hematuria, and on Bactrim DS one a day for ten days with a standard postprostatic surgery instruction sheet.  ,DISCHARGE DIAGNOSIS: , Enlarged prostate with benign bladder neck obstruction.  ,To be followed in my office in one week and by Dr. ABC next available as an outpatient.
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DESCRIPTION: Hispanic male patient was admitted because of enlarged prostate and symptoms of bladder neck obstruction.

discharge summary, tur, bun, cystourethroscopy, difficulty voiding, bladder neck obstruction, creatinine, cysto, enlarged prostate, transurethral resection of prostate, urinary stream, bladder neck, neck obstruction, prostate

The situation described in the discharge summary involves the routine management of a common urological condition (enlarged prostate and bladder neck obstruction). The patient underwent a standard procedure (cystourethroscopy and transurethral resection of the prostate), experienced no complications, and is being discharged in satisfactory condition. Given these factors, the scenario is not high-stakes since it indicates a typical postoperative recovery without significant complications or life-threatening issues. The follow-up care is routine, with monitoring by specialists. The stakes are relatively low in the context of medical assessments as it does not involve immediate life-threatening conditions or complex post-operative challenges.


Medical Specialty: Urology
Sample Name: Foreskin - Followup

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

urology, formal circumcision, median raphe, penis, gomco circumcision, gomco, circumcision, foreskin,

This situation involves a follow-up consultation for a routine examination of a foreskin in a 2-week-old infant. The primary concern is related to a slightly high insertion of the median raphe, but there are no significant health issues or severe complications mentioned. The recommendation includes a future circumcision, either now with caution or at one year of age. Given the patient's current condition is stable and non-urgent, the situation is low-stakes, with minimal immediate risk to the patient's health.


Medical Specialty: Surgery
Sample Name: Colonoscopy

PREOPERATIVE DIAGNOSIS:,  Iron deficiency anemia.,POSTOPERATIVE DIAGNOSIS:,  Diverticulosis.,PROCEDURE:,  Colonoscopy.,MEDICATIONS: , MAC.,PROCEDURE: , The Olympus pediatric variable colonoscope was introduced into the rectum and advanced carefully through the colon to the cecum identified by the ileocecal valve and the appendiceal orifice.  Preparation was good, although there was some residual material in the cecum that was difficult to clear completely.  The mucosa was normal throughout the colon.  No polyps or other lesions were identified, and no blood was noted.  Some diverticula were seen of the sigmoid colon with no luminal narrowing or evidence of inflammation.  A retroflex view of the anorectal junction showed no hemorrhoids.  The patient tolerated the procedure well and was sent to the recovery room.,FINAL DIAGNOSES:,1.  Diverticulosis in the sigmoid.,2.  Otherwise normal colonoscopy to the cecum.,RECOMMENDATIONS:,1.  Follow up with Dr. X as needed.,2.  Screening colonoscopy in 2 years.,3.  Additional evaluation for other causes of anemia may be appropriate.
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DESCRIPTION: Iron deficiency anemia.  Diverticulosis in the sigmoid.

surgery, olympus, colonoscope, iron deficiency anemia, diverticulosis, sigmoid, cecum, anemia, colonoscopy

The primary situation described involves a standard colonoscopy procedure that was completed successfully. No immediate complications or critical issues were noted during or after the procedure. Diverticulosis, a common condition, was identified and recommendations were made for follow-up. The stakes are not high as there were no immediate life-threatening conditions detected or intense surgical interventions described. The follow-up recommendations further imply manageable follow-up care rather than urgent treatment needs.