Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Aortobifemoral Bypass

PREOPERATIVE DIAGNOSIS:,  Aortoiliac occlusive disease.,POSTOPERATIVE DIAGNOSIS:, Aortoiliac occlusive disease.,PROCEDURE PERFORMED:, Aortobifemoral bypass.,OPERATIVE FINDINGS: , The patient was taken to the operating room.  The abdominal contents were within normal limits.  The aorta was of normal size and consistency consistent with arteriosclerosis.  A 16x8 mm Gore-Tex graft was placed without difficulty.  The femoral vessels were small somewhat thin and there was posterior packing, but satisfactory bypass was performed.,PROCEDURE: , The patient was taken to the operating room, placed in a supine position, and prepped and draped in the usual sterile manner with Betadine solution.  A longitudinal incision was made after a Betadine-coated drape was placed over the incisional area.  Longitudinal incision was made over each groin initially and carried down to the subcutaneous fat and fascia.  Hemostasis was obtained with electrocautery.  The common deep and superficial femoral arteries were exposed and then these incisions were covered with antibiotic soaked sponges.  Attention was then turned to the abdomen, where a longitudinal incision was made from the pubis xiphoid, carried down subcutaneous fat and fascia.  Hemostasis was obtained with electrocautery.  The abdomen was entered above the umbilicus and then this was extended with care inferiorly as the patient has undergone previous abdominal surgery.  Mild adhesions were lysed.  The omentum was freed.  The small and large intestine were run with no evidence of abnormalities.  The liver and gallbladder were within normal limits.  No abnormalities were noted.  At this point, the Bookwalter retractor was placed.  NG tube was placed in the stomach and placed on suction.  The intestines were gently packed intraabdominally and laterally.  The rest of the peritoneum was then opened.  The aorta was cleared, both proximally and distally.  The left iliac was completely occluded.  The right iliac was to be cleansed.  At this point, 5000 units of aqueous heparin was administered to allow take effect.  The aorta was then clamped below the renal arteries and opened in a longitudinal fashion.  A single lumbar was ligated with #3-0 Prolene.  The inferior mesenteric artery was occluded intraluminally and required no suture closure.  Care was taken to preserve collaterals.  The aorta was measured, and a 16 mm Gore-Tex graft was brought on the field and anastomosed to the proximal aorta using #3-0 Prolene in a running fashion.  Last stitch was tied.  Hemostasis was excellent.  The clamp was gradually removed and additional Prolene was placed in the right posterolateral aspect to obtain better hemostasis.  At this point, strong pulses were present within the graft.  The limbs were vented and irrigated.  Using bimanual technique, the retroperitoneal tunnels were developed immediately on top of the iliac arteries into the groin.  The grafts were then brought through these, care being taken to avoid twisting of the graft.  At this point, the right iliac was then ligated using #0 Vicryl and the clamp was removed.  Hemostasis was excellent.  The right common femoral artery was then clamped proximally and distally, opened with #11 blade extended with Potts scissors.  The graft was _____ and anastomosed to the artery using #5-0 Prolene in a continuous fashion with a stitch _______ running fashion.  Prior to tying the last stitch, the graft and artery were vented and the last stitch was tied.  Flow was initially restored proximally then distally with good results.  Attention was then turned to the left groin and the artery grafts were likewise exposed, cleared proximally and distally.  The artery was opened, extended with a Potts scissors and anastomosis was performed with #5-0 Prolene again with satisfactory hemostasis.  The last stitch was tied.  Strong pulses were present within the artery and graft itself.  At this point, 25 mg of protamine was administered.  The wounds were irrigated with antibiotic solution.  The groins were repacked.  Attention was then returned to the abdomen.  The retroperitoneal area and the anastomotic sites were checked for bleeding and none was present.  The shell of the aorta was closed over the proximal anastomosis and the retroperitoneum was then repaired over the remaining portions of the graft.  The intraabdominal contents were then allowed to resume their normal position.  There was no evidence of ischemia to the large or small bowel.  At this point, the omentum and stomach were repositioned.  The abdominal wall was closed in a running single layer fashion using #1 PDS.  The skin was closed with skin staples.  The groins were again irrigated, closed with #3-0 Vicryl and #4-0 undyed Vicryl and Steri-Strips.  The patient was then taken into the recovery room in satisfactory condition after tolerating the procedure well.  Sponges and instrument counts were correct.  Estimated blood loss 900 cc.
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DESCRIPTION: Aortoiliac occlusive disease.  Aortobifemoral bypass.  The aorta was of normal size and consistency consistent with arteriosclerosis.  A 16x8 mm Gore-Tex graft was placed without difficulty.  The femoral vessels were small somewhat thin and there was posterior packing, but satisfactory bypass was performed.

cardiovascular / pulmonary, aorta, bypass, arteriosclerosis, abdominal contents, aortoiliac occlusive disease, gore tex graft, aortobifemoral bypass, longitudinal incision, aortobifemoral, hemostasis, artery, graft,

This document describes a detailed surgical procedure, specifically an aortobifemoral bypass, which is a significant operation to treat aortoiliac occlusive disease. This type of surgery is associated with serious conditions, potential risks, and complications. The surgery involves major blood vessels, poses a risk of significant blood loss as noted with an estimated 900 cc of blood loss, and has a critical impact on the patient's vascular health. All these factors indicate that this situation is high-stakes because it directly impacts the patient's survival and quality of life. The detailed account of the surgery highlights the critical nature of the procedure and the precision required.


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

Medical Specialty: Obstetrics / Gynecology
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.

obstetrics / gynecology, 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 ultrasound findings indicate a normal, healthy pregnancy without complications. The data shows normal fetal heart rate, normal amniotic fluid levels, and no signs of fetal anomalies or complications such as placenta previa. This particular ultrasound seems to be a routine check-up for determining size and date of pregnancy, which is low-risk given the findings. Therefore, the stakes involved are relatively low.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Office Notes
Sample Name: Normal ENT Exam

EARS, NOSE, MOUTH AND THROAT: , The nose is without any evidence of any deformity.  The ears are with normal-appearing pinna.  Examination of the canals is normal appearing bilaterally.  There is no drainage or erythema noted.  The tympanic membranes are normal appearing with pearly color, normal-appearing landmarks and normal light reflex.  Hearing is grossly intact to finger rubbing and whisper.  The nasal mucosa is moist.  The septum is midline.  There is no evidence of septal hematoma.  The turbinates are without abnormality.  No obvious abnormalities to the lips.  The teeth are unremarkable.  The gingivae are without any obvious evidence of infection.  The oral mucosa is moist and pink.  There are no obvious masses to the hard or soft palate.  The uvula is midline.  The salivary glands appear unremarkable.  The tongue is midline.  The posterior pharynx is without erythema or exudate.  The tonsils are normal appearing.
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DESCRIPTION: Sample normal ear, nose, mouth, and throat exam.

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

The provided text is a description of a normal ENT exam, which is standard procedure and indicates routine documentation of a patient's clinical findings. There are no signs of abnormalities or urgent concerns based on the examination, making this a low-stakes situation in a medical context.


Medical Specialty: Surgery
Sample Name: EGD Template - 2

The patient was placed in the left lateral decubitus position, medicated with the above medications to achieve and maintain a conscious sedation.  Vital signs were monitored throughout the procedure without evidence of hemodynamic compromise or desaturation.,The Olympus single-channel endoscope was passed under direct visualization through the oral cavity and advanced to the second portion of the duodenum.,FINDINGS:,ESOPHAGUS:  Proximal and mid esophagus were without abnormalities.,STOMACH:  Insufflated and retroflexed visualization of the gastric cavity revealed,DUODENUM:  Normal.
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DESCRIPTION: Common description of EGD.

Common description of EGD.

surgery, gastric cavity, lateral decubitus position, endoscope, olympus, egd, visualization, cavity, duodenum, esophagusNOTE

The situation described is a routine endoscopic procedure (EGD) where the patient was under conscious sedation, and vital signs were stable throughout. There were no abnormalities detected in the esophagus, stomach, or duodenum, which indicates a negative result for any issues. In general, this type of procedure is low-risk and considered low-stakes since it’s routine and both the procedure and patient monitoring encountered no complications.


Medical Specialty: Orthopedic
Sample Name: Release of A1 Pulley

PREOPERATIVE DIAGNOSIS: , Right trigger thumb.,POSTOPERATIVE DIAGNOSIS:,  Right trigger thumb.,SURGERY: , Release of A1 pulley, CPT code 26055.,ANESTHESIA:,  General LMA.,TOURNIQUET TIME:  ,9 minutes at 200 torr.,FINDINGS:,  The patient was found to have limitations to extension at the IP joint to the right thumb.  He was found to have full extension after release of A1 pulley.,INDICATIONS:,  The patient is 2-1/2-year-old.  He has a history of a trigger thumb.  This was evaluated in the office.  He was indicated for release of A1 pulley to allow for full excursion.  Risks and benefits including recurrence, infection, and problems with anesthesia were discussed at length with the family.  They wanted to proceed.,PROCEDURE:,  The patient was brought into the operating room and placed on the operating table in supine position.  General anesthesia was induced without incident.  He was given a weight-adjusted dose of antibiotics.  The right upper extremity was then prepped and draped in a standard fashion.  Limb was exsanguinated with an Esmarch bandage.  Tourniquet was raised to 200 torr.  Transverse incision was then made at the base of thumb.  The underlying soft tissues were carefully spread in line longitudinally.  The underlying tendon was then identified.  The accompanied A1 pulley was also identified.  This was incised longitudinally using #11 blade.  Inspection of the entire tendon then demonstrated good motion both in flexion and extension.  The leaflets of the pulley were easily identified.,The wound was then irrigated and closed.  The skin was closed using interrupted #4-0 Monocryl simple sutures.  The area was injected with 5 mL of 0.25% Marcaine.  The wound was dressed with Xeroform, dry sterile dressings, hand dressing, Kerlix, and Coban.  The patient was awakened from anesthesia and taken to the recovery room in good condition.  There were no complications.  All instrument, sponge, needle counts were correct at the end of case.,PLAN: , The patient will be discharged home.  He will return in 1-1/2 weeks for wound inspection.
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DESCRIPTION: The patient was found to have limitations to extension at the IP joint to the right thumb and he had full extension after release of A1 pulley.

orthopedic, a1 pulley, release of a1 pulley, trigger thumb, limitations to extension, ip joint

The described surgical procedure, a Release of A1 Pulley for a 2.5-year-old patient with a trigger thumb, appears to be relatively routine and low-risk in the field of orthopedic surgery. While general anesthesia and surgical intervention always carry some inherent risks, the preoperative and postoperative diagnoses are the same, indicating a straightforward case without complications. The short tourniquet time, successful identification and treatment of the issue, absence of complications, and the plan for routine postoperative follow-up further suggest this is a low-stakes situation in the context of surgical procedures.


Medical Specialty: Ophthalmology
Sample Name: Phacoemulsification & Lens Implantation - 2

PROCEDURE PERFORMED: , Phacoemulsification with intraocular lens placement.,ANESTHESIA TYPE:  ,Topical.,COMPLICATIONS: , None.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room after the eye was dilated with topical Mydriacyl and Neo-Synephrine eye drops.  Topical anesthetic drops were applied to the eye just prior to entering the operating room.  The eye was then prepped with a 5% Betadine solution injected in the usual sterile fashion.  A wire speculum was placed in the eye and then a clear corneal paracentesis site was made inferiorly with a 15-degree blade.  Lidocaine 1% preservative-free, 0.1 cc, was instilled into the anterior chamber through the clear corneal paracentesis site and this was followed with viscoelastic to fill the chamber.  A 2.8-mm keratome was used to create a self-sealing corneal incision temporally and then a bent capsulotomy needle was used to create an anterior capsular flap.  The Utrata forceps were used to complete a continuous tear capsulorrhexis, and hydrodissection and hydrodelineation of the nucleus was performed with BSS on a cannula.  Phacoemulsification in a quartering and cracking technique was used to remove the nucleus, and then the residual cortex was removed with the irrigation and aspiration unit.  Gentle vacuuming of the central posterior capsule was performed with the irrigation and aspiration unit.  The capsular bag was re-expanded with viscoelastic, and then the wound was opened to a 3.4-mm size to accommodate the intraocular lens insertion using an additional keratome blade.,The lens was folded, inserted into the capsular bag and then unfolded.  The trailing haptic was tucked underneath the anterior capsular rim.  The lens was shown to center very well.  The viscoelastic was removed with the irrigation and aspiration unit and one 10-0 nylon suture was placed across the incision after Miochol was injected into the anterior chamber to cause pupillary constriction.  The wound was shown to be watertight.  Therefore, TobraDex ointment was applied to the eye, an eye pad loosely applied, and a Fox shield taped firmly in place over the eye.,The patient tolerated the procedure well and left the operating room in good condition.
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DESCRIPTION: Phacoemulsification with intraocular lens placement.  A wire speculum was placed in the eye and then a clear corneal paracentesis site was made inferiorly with a 15-degree blade.

ophthalmology, keratome, phacoemulsification, cortex, tobradex, intraocular lens, aspiration unit, topical, chamber, viscoelastic, corneal, capsular, lens, intraocular, eye,

The procedure described is a routine cataract surgery involving phacoemulsification and lens implantation. Although it is an invasive surgical procedure, it is considered low-risk and is commonly performed with a high success rate and low complication occurrence. The report indicates no complications. Given the routine nature of this surgery and the absence of complications, the stakes, in terms of patient risk and potential for adverse outcomes, are relatively low compared to more complex or high-risk surgeries.


Medical Specialty: Ophthalmology
Sample Name: Conjunctivitis

CONJUNCTIVITIS,, better known as Pink Eye, is an infection of the inside of your eyelid.  It is usually caused by allergies, bacteria, viruses, or chemicals.,WHAT ARE THE SIGNS AND SYMPTOMS?,1.  Red, irritated eye.,2.  Some burning and/or scratchy feeling.,3.  There may be a purulent (pus) or a mucous type discharge.,HOW IS IT TREATED?,It depends on what caused the Pink Eye.  It may or may not need medication for treatment.  If medication is given, follow the directions on the label.,TO PREVENT THE SPREAD OF THE INFECTION:,1.  Wash hands thoroughly before you use the medicine in your eyes.  After using the medicine in your eyes.  Every time you touch your eyes or face.,2.  Wash any clothing touched by infected eyes.,Clothes,Towels,Pillowcases,3.  Do not share make-up.  If the infection is caused by bacteria or a virus you must throw away your used make-up and buy new make-up.,4.  Do not touch the infected eye because the infection will spread to the good eye.  IMPORTANT!!!,5.  Pink Eye Spreads Very Easily!
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DESCRIPTION: A sample note on Conjunctivitis (Pink Eye).

ophthalmology, eyelid, infected eyes, pink eye, conjunctivitis, eyes, infection, eye

Conjunctivitis, or Pink Eye, while being a common and infectious condition, is typically not a life-threatening situation. It may cause discomfort and inconvenience, and it is highly contagious, which can lead to spread if not handled properly. However, the stakes remain low in terms of health impact, as it is generally treatable and not severe in terms of causing long-term damage or systemic illness. The primary concern is the spread of infection rather than serious health outcomes.


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

The patient's home regimen includes Duragesic patch at 125 mcg every 3 days.  She is currently on a Dilaudid PCA of 1 mg every 10 minutes lockout, Dilaudid boluses 2 mg q.3 h. p.r.n., Ativan 2 mg q.4 h., Tylenol per rectum.  The patient was offered multiple procedures to help with her abdominal pain including a thoracic epidural placement for sympathetic block for pain control and a celiac plexuses/neurolytic block.  The patient's family and she will continue to think about these pain procedures and let us know if they are interested in either.  For the moment, we will not make any further recommendations on her current medical management.  We did ask Dr. X, a psychiatrist, who works for the Pain Service to come in and see Ms. A as anxiety is a large component of her suffering at this time.,
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DESCRIPTION: A woman with end-stage peritoneal mesothelioma with multiple bowel perforations.

soap / chart / progress notes, pleurodesis, abdominal pain, multiple bowel perforations, peritoneal mesothelioma, mesothelioma, peritonealNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

The situation involves a patient with end-stage peritoneal mesothelioma, a severe and life-threatening condition. The management of her pain and anxiety is critical, as she is in significant distress. Decisions about additional procedures for pain management, like thoracic epidural placement and celiac plexus block, could have substantial implications for her quality of life in her remaining time. Moreover, the involvement of a psychiatrist for her anxiety indicates the complexity of her current healthcare needs. Therefore, the decisions being made about her care have high stakes in managing her symptoms and improving her comfort.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Shone complex

HISTORY AND PHYSICAL:  ,The patient is a 13-year-old, who has a history of Shone complex and has a complete heart block.  He is on the pacemaker.  He had a coarctation of the aorta and that was repaired when he was an infant.  He was followed in our Cardiology Clinic here and has been doing well.  However last night, he was sleeping, and he states he felt as if he has having a dream, and there was thunder in this dream, which woke him up.  He then felt that his defibrillator was going off and this has continued and feels like his heart rate is not normal.  Thus, his dad put him in the car and transported him here.  He has been evaluated here.  He had some scar tissue at one point when the internal pacemaker was not working properly and had to have that replaced.  It was 2 a.m. when he woke, and again, he was brought here by private vehicle.  He was well prior to going to bed.  No cough, cold, runny nose, fever.  No trauma has been noted.,PAST MEDICAL HISTORY:,  Shone complex, pacemaker dependent.,MEDICATIONS: , He is on no medications at this time.,ALLERGIES:,  He has no allergies.,IMMUNIZATIONS:,  Up to date.,SOCIAL HISTORY: , He lives with his parents.,FAMILY HISTORY: , Negative.,REVIEW OF SYSTEM: , Twelve asked, all negative, except as noted above.,PHYSICAL EXAMINATION:,GENERAL:  This is an awake, alert male, who appears to be in mild distress.,HEENT:  Pupils are equal, round, and reactive to light.  Extraocular movements are intact.  His TMs are clear.  His nares are clear.  The mucous membranes are pink and moist.  Throat is clear.,NECK:  Supple without lymphadenopathy or masses.  Trachea is midline.,LUNGS:  Clear.,HEART:  Shows bradycardia at 53.  He has good distal pulses.,ABDOMEN:  Soft, nontender.  Positive bowel sounds.  No guarding, no rebound.  No rashes are seen.,HOSPITAL COURSE:,  Initial blood pressure is 164/90.  He was moved in room 1.  He was placed on nasal cannula.  Pulse ox was 100%, which is normal.  We placed him on a monitor.  We did an EKG; it has not appear to be capturing his pacemaker at this time.  Shortly after the patient's arrival, the Medtronic technician came and worked out his pacemaker.  Medtronic representative informed me that the lead that he has in place has been recalled because it has been prone to microfractures, oversensing, and automatic defibrillation.  As noted, he was transferred to room 1, placed on a monitor, pulse ox.  An IV was placed.  A standard blood work was sent.  A chest x-ray was done showing normal heart size, lead appeared to be in placed.  There was no evidence of pulmonary edema.  His pacemaker did not appear to be capturing.  We placed him on transthoracic leads.  However, it is difficult to get good placement with these because of the area where his pacemaker was placed.  The Medtronic technician initially turned off his defibrillation mode and turned down his sensor.  However, we could not get our transthoracic pacer to capture his heart.  When the Medtronic representative turned off the pacemaker, the heart rate seemed to drop into the 40s.  The patient appeared to be in pain.  We placed it back on a rate of 60 at that time.  He has remained in sinus bradycardia, but no evidence of ectopic beats.  No widening of his QRS complex.  I spoke with Cardiology.  Cardiology service has come in, has evaluated him at bedside with me.  Again, we turned up the transthoracic pacer, but it is again not seem to be picking up, and his heart rate is still going with the Medtronic's internal pacemaker.  So with the ICU physician on call, Dr. X, he has agreed with taking this young man to the ICU.,An hour after presentation here, the ICU was ready for bed.  I accompanied the patient up to the ICU.  He remained awake and alert.  Initially, he was complaining of a lot of chest pain.  Once the defibrillator was turned off, he had no more pain.  He was transported to the Pediatrics PICU and delivered in stable condition.,LABORATORY DATA: , CBC was normal.  Chem-20 was normal as well.,IMPRESSION:  ,Complete heart block with pacemaker malfunction.,PLAN:  ,He is admitted to the ICU.,TIME SEEN: , Critical care time outside billable procedures was 45 minutes with this patient.  I should note that a 12-lead EKG was done here showing sinus bradycardia, normal intervals otherwise.
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DESCRIPTION: Complete heart block with pacemaker malfunction and  a history of Shone complex.

This case involves a pediatric patient with a history of Shone complex and complete heart block, requiring a pacemaker. The malfunction of the pacemaker poses a high risk to his cardiovascular stability and overall health. Immediate medical attention is critical due to potential life-threatening complications such as bradycardia, inadequate cardiac output, or heart failure. The involvement of specialists and ICU admission indicates the severity. This situation demands expert intervention to prevent further complications or mortality, making it a high-stakes medical scenario.


Medical Specialty: Orthopedic
Sample Name: Closed ORIF - Ankle

PREOPERATIVE DIAGNOSES:,1.  Trimalleolar ankle fracture.,2.  Dislocation right ankle.,POSTOPERATIVE DIAGNOSES:,1.  Trimalleolar ankle fracture.,2.  Dislocation right ankle.,PROCEDURE PERFORMED: , Closed open reduction and internal fixation of right ankle.,ANESTHESIA:  ,Spinal with sedation.,COMPLICATIONS:  ,None.,ESTIMATED BLOOD LOSS:  ,Minimal.,TOTAL TOURNIQUET TIME:  ,75 minutes at 325 mmHg.,COMPONENTS: , Synthes small fragment set was used including a 2.5 mm drill bed.  A six hole one-third tibial plate, one 12 mm 3.5 mm cortical screw fully threaded and two 16 mm 3.5 mm cortical fully-threaded screws.  There were two 20 mm 4.0 cancellous screws and one 18 mm 4.0 cancellous screw placed.  There were two 4.0 cancellous partially-threaded screws placed.,GROSS FINDINGS:  ,Include a comminuted fracture involving the lateral malleolus as well as a medial and posterior malleolus fracture as well.,HISTORY OF PRESENT ILLNESS: , The patient is an 87-year-old Caucasian female who presented to ABCD General Hospital Emergency Room complaining of right ankle pain status post a trip and fall.  The patient noted while walking with a walker, apparently tripped and fell.  The patient had significant comorbidities, seen and evaluated by the Emergency Room Department as well as Department of Orthopedics while in the Emergency Room.  At that time, a closed reduction was performed and she was placed in a Robert-Jones splint.  After complete medical workup and clearance, we elected to take her to the operating room for definitive care.,PROCEDURE:  ,After all potential complications and risks as well as risks and benefits of the above-mentioned procedure was discussed at length with the patient and family, informed consent was obtained.  The upper extremity was then confirmed with the operating surgeon, the patient, the nursing staff and Department of Anesthesia.  The patient was then transferred to preoperative area in the Operative Suite #3 and placed on the operating room table in supine position.  At this time, the Department of Anesthesia administered spinal anesthetic to the patient as well as sedation.  All bony prominences were well padded at this time.  A nonsterile tourniquet was placed on the right upper thigh of the patient.  This was then removed and the right lower extremity was sterilely prepped and draped in the usual sterile fashion.  The right lower extremity was then elevated and exsanguinated using Esmarch and tourniquet was then placed to 325 mmHg and kept up to a total of 75 minutes.  Next, after all bony and soft tissue landmarks were identified, a 6 cm longitudinal incision was made directly over this vestibule on the right ankle.  A sharp dissection was carefully taken down to the level of bone taking care to protect the neurovascular structures.  Once the bone was reached, the fractured site was identified.  The bony ends were then opened and divided of all hematoma as well as excess periosteum within the fracture site.  The wound was copiously irrigated and dried.  Next, the fracture was then reduced in anatomic position.  There was noted to be quite a bit of comminution as well as soft overall status of the bone.  It was held in place with reduction forceps.  A six hole one-third tubular Synthes plate was then selected for instrumentation.  It was contoured using ________ and placed on the lateral aspect of the distal fibula.  Next, the three most proximal holes were sequentially drilled using a 2.5 mm drill bed, depth gauged and then a 3.5 mm fully threaded cortical screw was placed in each.  The most proximal was a 12 mm and the next two were 16 mm in length.  Next, the three most distal holes were sequentially drilled using a 2.5 mm drill bed, depth gauged, and a 4.0 cancellous screw was placed in each hole.  The most distal with a 20 mm and two most proximal were 18 mm in length.  Next the Xi-scan was used to visualize the hardware placement as well as the fracture reduction appeared to be in good anatomic position, all hardware was in good position.  There was no lateralization of the joints.  Attention was then directed towards the medial aspect of the ankle.  Again, after all bony and soft tissue landmarks were identified, a 4 cm longitudinal incision was made directly over the medial malleolus.  Again, the dissection was carefully taken down the level of the fracture site.  The retractors were then placed to protect all neurovascular structures.  Once the fracture site was identified, it was dried of all hematoma as well as excess periosteum.  The fracture site was then displaced and the ankle joint was visualized including the dome of the talus.  There appeared to be some minor degenerative changes of the talus, but no loose bodies.  Next, the wound was copiously irrigated and suctioned dry.  The medial malleolus was placed in reduced position and held in place with a 1.25 mm K-wire.  Next, the 2.5 mm drill bed was then used to sequentially drill holes to full depth and 4.0 cancellous screws were placed in each, each with a 45 mm in length.  These appeared to hold the fracture site securely in an anatomic position.  Again, Xi-scan was brought in to confirm placement of the screws.  They were in good overall position and there was no lateralization of the joint.  At this time, each wound was copiously irrigated and suctioned dry.  The wounds were then closed using #2-0 Vicryl suture in subcutaneous fashion followed by staples on the skin.  A sterile dressing was applied consistent with Adaptic, 4x4s, Kerlix, and Webril.  A Robert-Jones style splint was then placed on the right lower extremity.  This was covered by a 4-inch Depuy dressing.  At this time, the Department of Anesthesia reversed the sedation.  The patient was transferred back to the hospital gurney and to the Postanesthetic Care Unit.  The patient tolerated the procedure well.  There were no complications.
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DESCRIPTION: Trimalleolar ankle fracture and dislocation right ankle.  A comminuted fracture involving the lateral malleolus, as well as a medial and posterior malleolus fracture as well.  Closed open reduction and internal fixation of right ankle.

orthopedic, ankle fracture, dislocation, open reduction, internal fixation, orif, trimalleolar ankle fracture, cortical screw, cancellous screws, fracture site, fracture, ankle, malleolus,

This surgical procedure involves a closed open reduction and internal fixation (ORIF) of a trimalleolar fracture and dislocation in an elderly patient. Such procedures typically hold significant stakes due to the patient's age, complexity of the fracture, potential for complications, and impact on the patient's mobility and quality of life. However, in this particular situation, there were no recorded complications during the operation, blood loss was minimal, and the patient tolerated the procedure well, which might reduce the immediate reporting stakes slightly in this case. However, overall surgical interventions, particularly in elderly patients, generally carry high stakes due to potential risks involved and the need for successful outcomes to maintain patient autonomy and mobility.


Medical Specialty: Surgery
Sample Name: Cemented Arthroplasty

PREOPERATIVE DIAGNOSIS: , Severe tricompartmental osteoarthritis, left knee with varus deformity.,POSTOPERATIVE DIAGNOSIS:,  Severe tricompartmental osteoarthritis, left knee with varus deformity.,PROCEDURE PERFORMED:  ,Left total knee cemented arthroplasty.,ANESTHESIA: , Spinal with Duramorph.,ESTIMATED BLOOD LOSS:  ,50 mL.,NEEDLE AND SPONGE COUNT:,  Correct.,SPECIMENS: , None.,TOURNIQUET TIME:  ,Approximately 77 minutes.,IMPLANTS USED:,1.  Zimmer NexGen posterior stabilized LPS-Flex GSF femoral component size D, left.,2.  All-poly patella, size 32/8.5 mm thickness.,3.  Prolong highly cross-linked polyethylene 12 mm.,4.  Stemmed tibial component, size 2.,5.  Palacos cement with antibiotics x2 batches.,INDICATION: , The patient is an 84-year-old female with significant endstage osteoarthritis of the left knee, who has had rapid progression with pain and disability.  Surgery was indicated to relieve her pain and improve her functional ability.  Goal objectives and the procedure were discussed with the patient.  Risks and benefits were explained.  No guarantees have been made or implied.  Informed consent was obtained.,DESCRIPTION OF THE PROCEDURE:  ,The patient was taken to the operating room and once an adequate spinal anesthesia with Duramorph was achieved, her left lower extremity was prepped and draped in a standard sterile fashion.  A nonsterile tourniquet was placed proximally in the thigh.  Antibiotics were infused prior to Foley catheter insertion.  Time-out procedure was called.,A straight longitudinal anterior midline incision was made.  Dissection was carried down sharply down the skin, subcutaneous tissue and the fascia.  Deep fascia was exposed.  The tourniquet was inflated at 300 mmHg prior to the skin incision.  A standard medial parapatellar approach was made.  The quadriceps tendon was incised approximately 1 cm from the vastus medialis insertion.  Incision was then carried down distally and distal arthrotomy was completed.  Patellar tendon was well protected.  Retinaculum and capsule was incised approximately 5 mm from the medial border of the patella for later repair.  The knee was exposed very well.  Significant tricompartmental osteoarthritis was noted.  The osteophytes were removed with a rongeur.  Anterior and posterior cruciate ligaments were excised.  Medial and lateral meniscectomies were performed.  Medial dissection was performed subperiosteally along the medial aspect of the proximal tibia to address the varus deformity.  The medial compartment was more affected than lateral.  Medial ligaments were tied.  Retropatellar fat pad was excised.  Osteophytes were removed.  Using a Cobb elevator, the medial soft tissue periosteum envelope was well reflected.,Attention was placed for the preparation of the femur.  The trochlear notch was ossified.  A rongeur was utilized to identify the notch and then using an intramedullary drill guide, a starting hole was created slightly anterior to the PCL attachment.  The anterior portal was 1 cm anterior to the PCL attachment.  The anterior femoral sizer was positioned keeping 3 degrees of external rotation.  Rotation was also verified using the transepicondylar axis and Whiteside line.  The pins were positioned in the appropriate holes.  Anterior femoral cut was performed after placing the cutting guide.  Now, the distal cutting guide was attached to the alignment and 5 degrees of valgus cut was planned.  A distal femoral cut was made which was satisfactory.  A sizer was positioned which was noted to be D.  The 5-in-1 cutting block size D was secured with spring pins over the resected bone.  Using an oscillating saw, cuts were made in a sequential manner such as anterior condyle, posterior condyle, anterior chamfer, and posterior chamfer.  Then using a reciprocating saw, intercondylar base notch cut and side cuts were made.  Following this, the cutting block for High-Flex knee was positioned taking 2 mm of additional posterior condyle.  Using a reciprocating saw, the side cuts were made and bony intercondylar notch cut was completed.  The bone with its attached soft tissue was removed.  Once the femoral preparation was completed, attention was placed for the preparation of the tibia.  The medial and the lateral collateral ligaments were well protected with a retractor.  The PCL retractor was positioned and the tibia was translated anteriorly.  Osteophytes were removed.  The extramedullary tibial alignment guide was affixed to the tibia and appropriate amount of external rotation was considered reference to the medial 1/3rd of the tibial tubercle.  Similarly, horseshoe alignment guide was positioned and the alignment guide was well aligned to the distal 1/3rd of the crest of the tibia as well as the 2nd toe.  Once the alignment was verified in a coronal plane, the tibial EM guide was well secured and then posterior slope was also aligned keeping the alignment rod parallel to the tibial crest.  A built-in 7-degree posterior slope was considered with instrumentation.  Now, the 2 mm stylus arm was positioned over the cutting block medially, which was the most affected site.  Tibial osteotomy was completed 90 degrees to the mechanical axis in the coronal plane.  The resected thickness of the bone was satisfactory taken 2 mm from the most affected site.  The resected surface shows some sclerotic bone medially.  Now, attention was placed for the removal of the posterior osteophytes from the femoral condyle.  Using curved osteotome, angle curette, and a rongeur, the posterior osteophytes were removed.  Now, attention was placed for confirming the flexion-extension gap balance using a 10 mm spacer block in extension and 12 mm in flexion.  Rectangular gap was achieved with appropriate soft tissue balance in both flexion and extension.  The 12 mm spacer block was satisfactory with good stability in flexion and extension.,Attention was now placed for completion of the tibia.  Size 2 tibial trial plate was positioned.  Appropriate external rotation was maintained with the help of the horseshoe alignment rod.  Reference to the tibial crest distally and 2nd toe was considered as before.  The midpoint of the trial tray was collinear with the medial 1/3rd of the tibial tubercle.  The rotation of tibial plate was satisfactory as required and the preparation of the tibia was completed with intramedullary drill followed by broach impactor.  At this point, trial femoral and tibial components were reduced using a 12 mm trial liner.  The range of motion and stability in both flexion and extension was satisfactory.  No further soft tissue release was indicated.  I was able to achieve 0 degrees of extension and complete flexion of the knee.,Attention was now placed for the preparation of the patella.  Using a patellar caliper, the thickness was measured to be 21.5 mm.  This gives an ideal resection of 8.5 mm keeping 13 mm of bone intact.  Reaming was initiated with a patellar reamer reaming up to 13 mm with the reaming alignment guide.  Using a caliper, the resected patella was measured, which was noted to be 13 mm.  A 32 sizer was noted to accommodate the resected surface very well.  Drilling was completed and trial 32 button was inserted without any difficulty.  The tracking was satisfactory.  There was no evidence of any subluxation or dislocation of the patella.  The trial components position was satisfactory.  The alignment and the rotation of all 3 components were satisfactory.  All the trial components were removed and the wound was thoroughly irrigated with Pulsavac lavage irrigation mechanical system.  The resected surfaces were dried with a sponge.  Two batches of Palacos cement were mixed.  The cementing was initiated starting with tibia followed by femur and patella.  Excess peripheral cement were removed with the curette and knife.  The knee was positioned in extension with a 12 mm trial liner.  Patellar clamp was placed after cementing the all-poly patella.  Once the cement was set hard and cured, tourniquet was deflated.  Hemostasis was achieved.  The trial 12 mm liner was replaced with definitive Prolong highly cross-linked polyethylene liner.  Range of motion and stability was verified at 0 degrees and flexion of 120 degrees.  Anterior-posterior drawer test was satisfactory.  Medial and lateral stability was satisfactory.  Patellar tracking was satisfactory.  The wound was thoroughly irrigated.  Hemostasis was achieved.  A local cocktail was injected, which included the mixture of 0.25% plain Marcaine, 30 mg of Toradol, and 4 mg of morphine.  The quadriceps mechanism and distal arthrotomy was repaired with #1 Vicryl in figure-of-8 fashion.  The subcutaneous closure was performed in layers using 2-0 Vicryl and 0 Vicryl followed by 2-0 Vicryl proximally.  The skin was approximated with staples.  Sterile dressings were placed including Xeroform, 4x4, ABD, and Bias.  The patient was then transferred to the recovery room in a stable condition.  There were no intraoperative complications noted.  She tolerated the procedure very well.
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DESCRIPTION: Left total knee cemented arthroplasty.  Severe tricompartmental osteoarthritis, left knee with varus deformity.

The situation involves a surgical procedure, which inherently comes with high risks and significant consequences if not performed correctly. The detailed description outlines the complexity and critical nature of the surgery, including preparation, ligament preservation, alignment, bone cutting, and cementing of implants. Even though the procedure was completed successfully without complications, the stakes involved in such surgical operations are high due to potential risks such as infection, improper alignment which can lead to additional pain or the need for another surgery, and risks associated with anesthesia. Therefore, the stakes in this situation can be determined as relatively high.


Medical Specialty: General Medicine
Sample Name: Gen Med Consult - 44

PAST MEDICAL HISTORY:  Include:,1.  Type II diabetes mellitus.,2.  Hypertension.,3.  Hyperlipidemia.,4.  Gastroesophageal reflux disease.,5.  Renal insufficiency.,6.  Degenerative joint disease, status post bilateral hip and bilateral knee replacements.,7.  Enterocutaneous fistula.,8.  Respiratory failure.,9.  History of atrial fibrillation.,10.  Obstructive sleep apnea.,11.  History of uterine cancer, status post total hysterectomy.,12.  History of ventral hernia repair for incarcerated hernia.,SOCIAL HISTORY:  The patient has been admitted to multiple hospitals over the last several months.,FAMILY HISTORY:  Positive for diabetes mellitus type 2 in both mother and her sister.,MEDICATIONS:  Currently include,,1.  Albuterol inhaler q.4 h.,2.  Paradox swish and spit mouthwash twice a day.,3.  Digoxin 0.125 mg daily.,4.  Theophylline 50 mg q.6 h.,5.  Prozac 20 mg daily.,6.  Lasix 40 mg daily.,7.  Humulin regular high dose sliding scale insulin subcu. q.6 h.,8.  Atrovent q.4 h.,9.  Lantus 12 units subcu. q.12 h.,10.  Lisinopril 10 mg daily.,11.  Magnesium oxide 400 mg three times a day.,12.  Metoprolol 25 mg twice daily.,13.  Nitroglycerin topical q.6 h.,14.  Zegerid 40 mg daily.,15.  Simvastatin 10 mg daily.,ALLERGIES:  Percocet, Percodan, oxycodone, and Duragesic.,REVIEW OF SYSTEMS:  The patient currently denies any pain, denies any headache or blurred vision.  Denies chest pain or shortness of breath.  She denies any nausea or vomiting.  Otherwise, systems are negative.,PHYSICAL EXAM:,General:  The patient is awake, alert, and oriented.  She is in no apparent respiratory distress.,Vital Signs:  Temperature 97.6, blood pressure is 139/53, pulse 100, respirations 24.  The patient has a tracheostomy in place.  She will also have an esophageal gastric tube in place.,Cardiac:  Regular rate and rhythm without audible murmurs, rubs or gallops.  Lungs are clear to auscultation bilaterally with slightly diminished breath sounds on the bases.  No adventitious sounds are noted.,Abdomen:  Obese.  There is an open wound on the ventral abdomen overlying the midline abdominal incision from previous surgery.  The area is covered with bandage with serosanguineous fluid.  Abdomen is nontender to palpation.  Bowel sounds are heard in all 4 quadrants.,Extremities:  Bilateral lower extremities are edematous and very cool to touch.,LABORATORY DATA:  Pending.  Capillary blood sugars thus far have been 132 and 135.,ASSESSMENT:  This is an 80-year-old female with an unfortunate past medical history with recent complications of sepsis and respiratory failure who is now receiving tube feeds.,PLAN:  For her diabetes mellitus, we will continue the patient on her current regimen of Lantus 12 units subcu. q.12 h. and Regular Insulin at a high dose sliding scale every 6 hours.  The patient had been previously controlled on this.  We will continue to check her sugars every 6 hours and adjust insulin as necessary.
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DESCRIPTION: An 80-year-old female with recent complications of sepsis and respiratory failure who is now receiving tube feeds.

The patient is an elderly woman with a complex medical history, including multiple chronic conditions that are significant in nature, such as type II diabetes, hypertension, hyperlipidemia, and respiratory failure. She also has a history of sepsis, which is a severe and potentially life-threatening condition. Her current physiological status is concerning, with factors such as tracheostomy, an esophageal gastric tube, cool edematous extremities, and a ventral abdominal wound. Overall, her situation is highly complex due to the interplay of multiple serious health issues that require careful monitoring and management. This increases the stakes significantly when it comes to her medical treatment and outcomes.


Medical Specialty: Neurology
Sample Name: Intractable Epilepsy

CHIEF COMPLAINT:,  Intractable epilepsy, here for video EEG.,HISTORY OF PRESENT ILLNESS: , The patient is a 9-year-old male who has history of global developmental delay and infantile spasms.  Ultimately, imaging study shows an MRI with absent genu of the corpus callosum and thinning of the splenium of the corpus callosum, showing a pattern of cerebral dysgenesis.  He has had severe global developmental delay, and is nonverbal.  He can follow objects with his eyes, but has no ability to interact with his environment to any great degree.  He has noted if any purposeful use of the hands.  He has abnormal movements constantly, which are more choreiform and dystonic.  He has spastic quadriparesis, which is variable at times.  The patient is unable to sit or stand, and receives all his nutrition via G-tube.,The patient began having seizures in infancy presenting as infantile spasms.  I began seeing him at 20 months of age.  At that point, he had undergone workup in Seattle, Washington and then was seeing Dr. X, child neurologist in Mexico, who started Vigabatrin for infantile spasms.  The patient had benefit from this medication, and was doing well at that time with regard to that seizure type.  He initially was on phenobarbital, which failed to give him benefit.  He continued on phenobarbital; however, for a long period time thereafter.  The patient then began having more tonic seizures after his episodic spasms had subsided, and failed several medication trials including valproic acid, Topamax, and Zonegran at least briefly.  Upon starting Lamictal, he began to have benefit and then actually had 1-year seizure freedom before having an isolated seizure or 2.  Over the next 6 months to a year, he only had few further seizures, and was doing well in a general sense.  It was more recently that he began having new seizure events that have not responded to higher doses of Lamictal up to 15 mg/kg/day.  These events manifest as tonic spells with eye deviation and posturing.  Mother reports flexion of the upper extremities, extension with lower extremities.  During that time, he is not able to cry or say any sounds.  These events last from seconds to minutes, and occur at least multiple times per week.  There are times where he has none for a few days and other times where he has multiple days in a row with events.  He has another event manifesting as flexion of the upper extremities and extension lower extremities where he turns red and cries throughout.  He may vomit after these episodes, then seems to calm down.  It is unclear whether this is a seizure or whether the patient is still responsive.,MEDICATIONS:,  The patient's medications include Lamictal for a total of 200 mg twice a day.  It is a 150 mg tablet and 25 mg tablets.  He is on Zonegran using 25 mg capsules 2 capsules twice daily, and baclofen 10 mg three times day.  He has other medications including the Xopenex and Atrovent.,REVIEW OF SYSTEMS: , At this time is negative any fevers, nausea, vomiting, diarrhea, abdominal complaints, rashes, arthritis, or arthralgias.  No respiratory or cardiovascular complaints.  He has no change in his skills at this point.,FAMILY HISTORY: , Noncontributory.,PHYSICAL EXAMINATION:,GENERAL:  The patient is a slender male who is microcephalic.  He has EEG electrodes in place and is on the video EEG at that time.,HEENT:  His oropharynx shows no lesions.,NECK:  Supple without adenopathy.,CHEST:  Clear to auscultation.,CARDIOVASCULAR:  Regular rate and rhythm.  No murmurs.,ABDOMEN:  Benign with G-tube in place.,EXTREMITIES:  Reveal no clubbing, cyanosis, or edema.,NEUROLOGICAL:  The patient is alert and has bilateral esotropia.  He is able to fix and follow objects briefly.  He is unable to reach for objects.  He exhibits constant choreiform movements when excited.  These are more prominent in the upper extremities and lower extremities.  He has some dystonic posture with flexion of the wrist and fingers bilaterally.  He also has plantar flexion at the ankles bilaterally.  His cranial nerves reveal that his pupils are equal, round, and reactive to light.  Extraocular movements are intact other than bilateral esotropia.  His face moves symmetrically.  Palate elevates in midline.  Hearing appears intact bilaterally.,Motor exam reveals dystonic and variable tone, overall there is mild in spasticity both upper and lower extremities as described above.  He has clonus at the ankles bilaterally, and some valgus contracture of the ankles.  His sensation is intact to light touch bilaterally.  Deep tendon reflexes are 2 to 3+ bilaterally.,IMPRESSION/PLAN: , This is a 9-year-old male with congenital brain malformation and intractable epilepsy.  He has microcephaly as well as dystonic cerebral palsy.  He had a re-emergence of seizures, which are difficult to classify, although some sound like tonic episodes and others are more concerning for non-epileptic phenomenon, such as discomfort.  He is admitted for video EEG to hopefully capture both of these episodes and further clarify the seizure type or types.  He will remain hospitalized for probably at least 48 hours to 72 hours.  He could be discharged sooner if multiple events are captured.  His medications, we will continue his current dose of Zonegran and Lamictal for now.  Both of these medications are very long acting, discontinuing them while in the hospital may simply result in severe seizures after discharge.
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DESCRIPTION: Intractable epilepsy, here for video EEG.

neurology, brain malformation, congenital, intractable epilepsy, global developmental delay, video eeg, seizures, intractable, eeg,

This is a high-stakes medical situation involving a child with intractable epilepsy and other serious neurological and developmental issues. The patient has a history of complex seizures and congenital brain malformations, requiring precise and possibly urgent medical interventions to manage his condition and improve his quality of life. The ongoing video EEG monitoring is crucial for capturing seizure events to better understand and manage the seizures. The stakes are high due to the potential impact on the child's health, development, and well-being if not properly managed.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Thoracotomy & Esophageal Exploration

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

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

The situation describes a surgical procedure involving a thoracotomy and esophageal exploration to address an esophageal rupture in a patient with a chronic esophageal stricture. This type of surgery is complex, involves multiple steps such as drainage of the pleural fluid and repairing the esophageal perforation, and carries significant risk due to possible complications. The presence of purulent fluid and the described complications with stitching the tissue add to the complexity and potential severity of the operation. These factors make this a high-stakes medical scenario, particularly because the patient's life could be at risk if the rupture leads to further complications like infection or respiratory distress.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: SOAP - Lung Mass

SUBJECTIVE:,  The patient is admitted for lung mass and also pleural effusion.  The patient had a chest tube placement, which has been taken out.  The patient has chronic atrial fibrillation, on anticoagulation.  The patient is doing fairly well.  This afternoon, she called me because heart rate was in the range of 120 to 140.  The patient is lying down.  She does have shortness of breath, but denies any other significant symptoms.,PAST MEDICAL HISTORY:,  History of mastectomy, chest tube placement, and atrial fibrillation; chronic.,MEDICATIONS:,1.  Cardizem, which is changed to 60 mg p.o. t.i.d.,2.  Digoxin 0.25 mg daily.,3.  Coumadin, adjusted dose.,4.  Clindamycin.,PHYSICAL EXAMINATION,VITAL SIGNS:  Pulse 122 and blood pressure 102/68.,LUNGS:  Air entry decreased.,HEART:  PMI is displaced.  S1 and S2 are irregular.,ABDOMEN:  Soft and nontender.,IMPRESSION:,1.  Pulmonary disorder with lung mass.,2.  Pleural effusion.,3.  Chronic uncontrolled atrial fibrillation secondary to pulmonary disorder.,RECOMMENDATIONS:,1.  From cardiac standpoint, follow with pulmonary treatment.,2.  The patient has an INR of 2.09.  She is on anticoagulation.  Atrial fibrillation is chronic with the rate increased.,Adjust the medications accordingly as above.
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DESCRIPTION: Pulmonary disorder with lung mass, pleural effusion, and chronic uncontrolled atrial fibrillation secondary to pulmonary disorder. The patient is admitted for lung mass and also pleural effusion.  The patient had a chest tube placement, which has been taken out.  The patient has chronic atrial fibrillation, on anticoagulation.

soap / chart / progress notes, lung mass, pleural effusion, chest tube placement, chest tube, pulmonary disorder, atrial fibrillation, chest, anticoagulation, effusion, lung, pulmonary, atrial, fibrillation,

The medical situation involves multiple serious health issues such as a lung mass, pleural effusion, and chronic uncontrolled atrial fibrillation. These conditions are compounded by the patient's need for anticoagulation, which complicates the management of atrial fibrillation. The elevated heart rate and shortness of breath indicate that the patient is experiencing symptoms that could lead to further complications if not managed properly. Hence, it is a high-stakes situation requiring careful monitoring and treatment adjustments.


Medical Specialty: Pain Management
Sample Name: Superior Gluteal Nerve Block

PRE-OPERATIVE DIAGNOSIS:, Superior Gluteal Neuralgia/Neurapraxia-impingement Syndrome.,POST-OPERATIVE DIAGNOSIS:, Same,PROCEDURE:, Superior Gluteal Nerve Block, Left.,After verbal informed consent, whereby the patient is made aware of the risks of the procedure, the patient was placed in the standing position with the arms flaccid by the side. Alcohol was used to prep the skin 3 times, and a 27-gauge needle was advanced deep to the attachment of the Gluteus Medius Muscle near its attachment on the PSIS. The needle entered the plane between the Gluteus Medius and Gluteus Maximus Muscle, in close proximity to the Superior Gluteal Nerve. Aspiration was negative, and the mixture was easily injected. Aseptic technique was observed at all times, and there were no complications noted.,INJECTATE INCLUDED:,Methyl Prednisolone (DepoMedrol): 20 mg,Ketorolac (Toradol): 6 mg,Sarapin: 1 cc,Bupivacaine (Marcaine): Q.S.  2 cc.,The procedures, above were performed for diagnostic, as well as therapeutic purposes. This treatment plan is medically necessary to decrease pain and suffering, increase activities of daily living and improve sleep.,ZUNG SELF-RATING DEPRESSION SCALE© (SDS) RESULTS:, The patient scored as 'mildly depressed.,NOTE:, The pain was gone post procedure, consistent with the diagnosis, as well as with adequacy of medication placement.
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DESCRIPTION: Superior Gluteal Nerve Block, Left - Superior Gluteal Neuralgia/Neurapraxia-impingement Syndrome.

pain management, neurapraxia, impingement syndrome, neuralgia, superior gluteal, superior gluteal nerve block, gluteus medius muscle, gluteus maximus muscle, gluteus medius, nerve block, gluteal nerve, block, gluteus, nerve, gluteal

The procedure involves administering a nerve block to alleviate pain, which is a routine and common practice in pain management. While it is a medical procedure, it's considered minimally invasive with a low risk of complications when performed properly. The stakes primarily involve ensuring proper pain management for the patient, rather than life-threatening concerns.


Medical Specialty: Orthopedic
Sample Name: Orthopedic Consult - 3

CHIEF COMPLAINT:,  Back pain and right leg pain.  The patient has a three-year history of small cell lung cancer with metastases.,HISTORY OF PRESENT ILLNESS:,  The patient is on my schedule today to explore treatment of the above complaints.  She has a two-year history of small cell lung cancer, which she says has spread to metastasis in both femurs, her lower lumbar spine, and her pelvis.  She states she has had numerous chemotherapy and radiation treatments and told me that she has lost count.  She says she has just finished a series of 10 radiation treatments for pain relief.  She states she continues to have significant pain symptoms.  Most of her pain seems to be in her low back on the right side, radiating down the back of her right leg to her knee.  She has also some numbness in the bottom of her left foot, and some sharp pain in the left foot at times.  She complains of some diffuse, mid back pain.  She describes the pain as sharp, dull, and aching in nature.  She rates her back pain as 10, her right leg pain as 10, with 0 being no pain and 10 being the worst possible pain.  She states that it seems to be worse while sitting in the car with prolonged sitting, standing, or walking.  She is on significant doses of narcotics.  She has had multiple CT scans looking for metastasis.,PAST MEDICAL HISTORY:,  Significant for cancer as above.  She also has a depression.,PAST SURGICAL HISTORY:,  Significant for a chest port placement.,CURRENT MEDICATIONS:,  Consist of Duragesic patch 250 mcg total, Celebrex 200 mg once daily, iron 240 mg twice daily, Paxil 20 mg daily, and Percocet.  She does not know of what strength up to eight daily.  She also is on warfarin 1 mg daily, which she states is just to keep her chest port patent.  She is on Neurontin 300 mg three times daily.,HABITS:,  She smokes one pack a day for last 30 years.  She drinks beer approximately twice daily.  She denies use of recreational drugs.,SOCIAL HISTORY:,  She is married.  She lives with her spouse.,FAMILY HISTORY: , Significant for two brothers and father who have cancer.,REVIEW OF SYSTEMS:,  Significant mainly for her pain complaints.  For other review of systems the patient seems stable.,PHYSICAL EXAMINATION:,General:  Reveals a pleasant somewhat emaciated Caucasian female.,Vital Signs:  Height is 5 feet 2 inches.  Weight is 130 pounds.  She is afebrile.,HEENT:  Benign.,Neck:  Shows functional range of movements with a negative Spurling's.,Chest:  Clear to auscultation.,Heart:  Regular rate and rhythm.,Abdomen:  Soft, regular bowel sounds.,Musculoskeletal:  Examination shows functional range of joint movements.  No focal muscle weakness.  She is deconditioned.,Neurologic:  She is alert and oriented with appropriate mood and affect.  The patient has normal tone and coordination.  Reflexes are 2+ in both knees and absent at both ankles.  Sensations are decreased distally in the left foot, otherwise intact to pinprick.,Spine:  Examination of her lumbar spine shows normal lumbar lordosis with fairly functional range of movement.  The patient had significant tenderness at her lower lumbar facet and sacroiliac joints, which seems to reproduce a lot of her low back and right leg complaints.,FUNCTIONAL EXAMINATION: , Gait has a normal stance and swing phase with no antalgic component to it.,INVESTIGATION: , She has had again multiple scans including a whole body bone scan, which showed abnormal uptake involving the femurs bilaterally.  She has had increased uptake in the sacroiliac joint regions bilaterally.  CT of the chest showed no evidence of recurrent metastatic disease.  CT of the abdomen showed no evidence of metastatic disease.  MRI of the lower hip joints showed heterogenous bone marrow signal in both proximal femurs.  CT of the pelvis showed a trabecular pattern with healed metastases.  CT of the orbits showed small amount of fluid in the mastoid air cells on the right, otherwise normal CT scan.  MR of the brain showed no acute intracranial abnormalities and no significant interval changes.,IMPRESSION:,1.  Small cell lung cancer with metastasis at the lower lumbar spine, pelvis, and both femurs.,2.  Symptomatic facet and sacroiliac joint syndrome on the right.,3.  Chronic pain syndrome.,RECOMMENDATIONS:,  Dr. XYZ and I discussed with the patient her pathology.  Dr. XYZ explained her although she does have lung cancer metastasis, she seems to be symptomatic with primarily pain at her lower lumbar facet and sacroiliac joints on the right.  Secondary to the patient's significant pain complaints today, Dr. XYZ will plan on injecting her right sacroiliac and facet joints under fluoroscopy today.  I explained the rationale for the procedure, possible complications, and she voiced understanding and wished to proceed.  She understands that she is on warfarin therapy and that we generally do not perform injections while they are on this.  We have asked for stat protime today.  She is on a very small dose, she states she has had previous biopsies while on this before, and did not have any complications.  She is on significant dose of narcotics already, however, she continues to have pain symptoms.  Dr. XYZ advised that if she continues to have pain, even after this injection, she could put on an extra 50 mcg patch and take a couple of extra Percocet if needed.  I will plan on evaluating her in the Clinic on Tuesday.  I have also asked that she stop her Paxil, and we plan on starting her on Cymbalta instead.  She voiced understanding and is in agreement with this plan.  I have also asked her to get an x-ray of the lumbar spine for further evaluation.  Physical exam, findings, history of present illness, and recommendations were performed with and in agreement with Dr. G's findings.  Peripheral neuropathy of her left foot is most likely secondary to her chemo and radiation treatments.
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DESCRIPTION: Back pain and right leg pain.  Small cell lung cancer with metastasis at the lower lumbar spine, pelvis, and both femurs

This situation involves a patient with a history of small cell lung cancer with metastases, experiencing significant pain and undergoing complex treatment plans involving narcotics and potential joint injections. The patient is dealing with high levels of pain despite significant management efforts, and there's the presence of multiple metastases, making the patient's condition quite serious. The decision to proceed with invasive procedures like joint injections and the use of heavy narcotics, along with dealing with potential complications from medication interactions (like warfarin), creates a high-stakes medical scenario. The patient's quality of life is profoundly affected by pain, and the medical decisions being made may significantly impact their well-being.