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

Medical Specialty: Neurosurgery
Sample Name: Laminotomy & Microdissection

PREOPERATIVE DIAGNOSES:  ,1.  Fractured and retained lumbar subarachnoid spinal catheter.,2.  Pseudotumor cerebri (benign intracranial hypertension).,PROCEDURES:  ,1.  L1 laminotomy.,2.  Microdissection.,3.  Retrieval of foreign body (retained lumbar spinal catheter).,4.  Attempted insertion of new external lumbar drain.,5.  Fluoroscopy.,ANESTHESIA: , General.,HISTORY:  ,The patient had a lumbar subarachnoid drain placed yesterday.  All went well with the surgery.  The catheter stopped draining and on pulling back the catheter, it fractured and CT scan showed that the remaining fragment is deep to the lamina.  The patient continues to have right eye blindness and headaches, presumably from the pseudotumor cerebri.,DESCRIPTION OF PROCEDURE:  ,After induction of general anesthesia, the patient was placed prone on the operating room table resting on chest rolls.  Her face was resting in a pink foam headrest.  Extreme care was taken positioning her because she weighs 92 kg.  There was a lot of extra padding for her limbs and her limbs were positioned comfortably.  The arms were not hyperextended.  Great care was taken with positioning of the head and making sure there was no pressure on her eyes especially since she already has visual disturbance.  A Foley catheter was in place.  She received IV Cipro 400 mg because she is allergic to most antibiotics.,Fluoroscopy was used to locate the lower end of the fractured catheter and the skin was marked.  It was also marked where we would try to insert the new catheter at the L4 or L3 interspinous space.,The patient was then prepped and draped in a sterile manner.,A 7-cm incision was made over the L1 lamina.  The incision was carried down through the fascia all the way down to the spinous processes.  A self-retaining McCullough retractor was placed.  The laminae were quite deep.  The microscope was brought in and using the Midas Rex drill with the AM-8 bit and removing some of the spinous process of L1-L2 with double-action rongeurs, the laminotomy was then done using the drill and great care was taken and using a 2-mm rongeur, the last layer of lamina was removed exposing the epidural fat and dura.  The opening in the bone was 1.5 x 1.5 cm.,Occasionally, bipolar cautery was used for bleeding of epidural veins, but this cautery was kept to a minimum.,Under high magnification, the dura was opened with an 11 blade and microscissors.  At first, there was a linear incision vertically to the left of midline, and I then needed to make a horizontal incision more towards the right.  The upper aspect of the cauda equina was visualized and perhaps the lower end of the conus.  Microdissection under high magnification did not expose the catheter.  The fluoroscope was brought in 2 more times including getting a lateral view and the fluoroscope appeared to show that the catheter should be in this location.,I persisted with intensive microdissection and finally we could see the catheter deep to the nerves and I was able to pull it out with the microforceps.,The wound was irrigated with bacitracin irrigation.,At this point, I then attempted lumbar puncture by making a small incision with an 11 blade in the L4 interspinous space and then later in the L3 interspinous space and attempted to puncture the dural sac with the Tuohy needle.  Dr. Y also tried.  Despite using the fluoroscope and our best attempts, we were not able to convincingly puncture the lumbar subarachnoid space and so the attempted placement of the new lumbar catheter had to be abandoned.  It will be done at a later date.,I felt it was unsafe to place a new catheter at this existing laminotomy site because it was very high up near the conus.  The potential for complications involving her spinal cord was greater and we have already had a complication of the catheter now and I just did not think it was safe to put in this location.,Under high magnification, the dura was closed with #6-0 PDS interrupted sutures.,After the dura was closed, a piece of Gelfoam was placed over the dura.  The paraspinous muscles were closed with 0 Vicryl interrupted sutures.  The subcutaneous fascia was also closed with 0 Vicryl interrupted suture.  The subcutaneous layer was closed with #2-0 Vicryl interrupted suture and the skin with #4-0 Vicryl Rapide.  The 4-0 Vicryl Rapide sutures were also used at the lumbar puncture sites to close the skin.,The patient was then turned carefully on to her bed after sterile dressings were applied and then taken to the recovery room.  The patient tolerated procedure well.  No complications.  Sponge and needle counts correct.  Blood loss minimal, none replaced.  This procedure took 5 hours.  This case was also extremely difficult due to patient's size and the difficulty of locating the catheter deep to the cauda equina.
---
DESCRIPTION: L1 laminotomy, microdissection, retrieval of foreign body (retained lumbar spinal catheter), attempted insertion of new external lumbar drain, and fluoroscopy.

neurosurgery, laminotomy, microdissection, lumbar spinal catheter, external lumbar drain, fluoroscopy, lumbar subarachnoid, spinal catheter, intracranial hypertension, vicryl interrupted sutures, lumbar, catheter,

The situation involves a complex neurosurgical procedure dealing with a fractured spinal catheter and a condition known as pseudotumor cerebri. The retrieval of a retained object near the spinal cord and decision-making about catheter placement involve high precision and inherent risks associated with neurosurgery. The stakes are high due to potential serious complications, such as damage to the spinal cord or further complications from the patient's existing condition. The procedure's complexity, the need for precise surgical interventions, and potential life-altering outcomes contribute to this being a high-stakes situation.


Medical Specialty: Endocrinology
Sample Name: Weight Gain and Edema

HISTORY OF PRESENT ILLNESS:,  This is a 55-year-old female with a history of I-131-induced hypothyroidism years ago who presents with increased weight and edema over the last few weeks with a 25-pound weight gain.  She also has a history of fibromyalgia, inflammatory bowel disease, Crohn disease, COPD, and disc disease as well as thyroid disorder.  She has noticed increasing abdominal girth as well as increasing edema in her legs.  She has been on Norvasc and lisinopril for years for hypertension.  She has occasional sweats with no significant change in her bowel status.  She takes her thyroid hormone apart from her Synthroid.  She had been on generic for the last few months and has had difficulty with this in the past.,MEDICATIONS: , Include levothyroxine 300 mcg daily, albuterol, Asacol, and Prilosec.  Her amlodipine and lisinopril are on hold.,ALLERGIES:,  Include IV DYE, SULFA, NSAIDS, COMPAZINE, and DEMEROL.,PAST MEDICAL HISTORY:,  As above includes I-131-induced hypothyroidism, inflammatory bowel disease with Crohn, hypertension, fibromyalgia, COPD, and disc disease.,PAST SURGICAL HISTORY: , Includes a hysterectomy and a cholecystectomy.,SOCIAL HISTORY: , She does not smoke or drink alcohol.,FAMILY HISTORY: , Positive for thyroid disease but the sister has Graves disease, as well a sister with Hashimoto thyroiditis.,REVIEW OF SYSTEMS: , Positive for fatigue, sweats, and weight gain of 20 pounds.  Denies chest pain or palpitations.  She has some loosening stools, but denies abdominal pain.  Complains of increasing girth and increasing leg swelling.,PHYSICAL EXAMINATION:,GENERAL:  She is an obese female.,VITAL SIGNS:  Blood pressure 140/70 and heart rate 84.  She is afebrile.,HEENT:  She has no periorbital edema.  Extraocular movements were intact.  There was moist oral mucosa.,NECK:  Supple.  Her thyroid gland is atrophic and nontender.,CHEST:  Good air entry.,CARDIOVASCULAR:  Regular rate and rhythm.,ABDOMEN:  Benign.,EXTREMITIES:  Showed 1+ edema.,NEUROLOGIC:  She was awake and alert.,LABORATORY DATA:,  TSH 0.28, free T4 1.34, total T4 12.4 and glucose 105.,IMPRESSION/PLAN:,  This is a 55-year-old female with weight gain and edema, as well as history of hypothyroidism.  Hypothyroidism is secondary to radioactive iodine for Graves disease many years ago.  She is clinically and biochemically euthyroid.  Her TSH is mildly suppressed, but her free T4 is normal and with her weight gain I will not decrease her dose of levothyroxine.  I will continue on 300 mcg daily of Synthroid.  If she wanted to lose significant weight, I shall repeat thyroid function test in six weeks' time to ensure that she is not hyperthyroid.
---
DESCRIPTION: This is a 55-year-old female with weight gain and edema, as well as history of hypothyroidism.  She also has a history of fibromyalgia, inflammatory bowel disease, Crohn disease, COPD, and disc disease as well as thyroid disorder.

The situation involves a 55-year-old female with a complex medical history including hypothyroidism, significant weight gain, and edema, which could indicate underlying health issues. Although the patient's thyroid levels are currently stable, the weight gain and edema need careful monitoring due to potential cardiovascular or renal implications. However, since she is currently euthyroid and under observation by a healthcare professional, the immediate risk is moderate rather than critical. The situation requires careful management, but there is no immediate life-threatening situation at hand.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: ENT - Otolaryngology
Sample Name: Postop Parathyroid Exploration & Parathyroidectomy

SUMMARY:  ,This patient is one-day postop open parathyroid exploration with subtotal parathyroidectomy and intraoperative PTH monitoring for parathyroid hyperplasia.  She has had an uneventful postoperative night.  She put out 1175 mL of urine since surgery.  Her incision looks good.  IV site and extremities are unremarkable.,LABORATORY DATA:  ,Her calcium level was 7.5 this morning.  She has been on three Tums orally b.i.d. and I am increasing three Tums orally q.i.d. before meals and at bedtime.,PLAN:,  I will heparin lock her IV, advance her diet, and ambulate her.  I have asked her to increase her prednisone when she goes home.  She will double her regular dose for the next five days.  I will advance her diet.  I will continue to monitor her calcium levels throughout the day.  If they stabilize, I am hopeful that she will be ready for discharge either later today or tomorrow.  She will be given Lortab Elixir 2 to 4 teaspoons orally every four hours p.r.n. pain, dispensed #240 mL with one refill.  Her final calcium dosage will be determined prior to discharge.  I will plan to see her back in the office on the 12/30/08, and she has been instructed to call or return sooner for any problems.
---
DESCRIPTION: This patient is one-day postop open parathyroid exploration with subtotal parathyroidectomy and intraoperative PTH monitoring for parathyroid hyperplasia.  She has had an uneventful postoperative night.

ent - otolaryngology, parathyroid hyperplasia, parathyroid exploration, pth, hyperplasia, parathyroidectomy, parathyroidNOTE

The patient is recovering from a parathyroid surgery, and though her postoperative night has been uneventful, there are potential complications that need monitoring, such as calcium level stability. The risk of hypocalcemia is present due to her low calcium level of 7.5. There is a detailed follow-up and monitoring plan, important for patient safety, but at present, no immediate life-threatening issue has arisen. However, close monitoring is crucial to ensure a smooth recovery, making this a moderate stakes situation.


Medical Specialty: Emergency Room Reports
Sample Name: Syncope - ER Visit

REASON FOR CONSULTATION:,  Syncope.,HISTORY OF PRESENT ILLNESS: , The patient is a 78-year-old lady followed by Dr. X in our practice with history of coronary artery disease, status post coronary artery bypass grafting in 2005 presented to the emergency room following a syncopal episode.  According to the patient and the daughter who was with her, she was shopping when she felt abdominal discomfort with nausea, profuse sweating, and passed out.  As soon as she was laid on the floor and her leg raised up, she woke up with no post-event confusion.  According to the daughter, she has had episodes of weakness, but no syncope.  She has blood pressure medications and has had some postural hypotensions, which has been managed by Dr. X. She also states there was a history of pulmonary embolism and the presentation at that time was very similar when she had a syncopal episode.  At that time, she was admitted at Hospital, had a V/Q scan, which was positive for PE.  Initial V/Q scan done at Hospital was negative.  She was anticoagulated with Coumadin resulting in severe GI bleed.  Anticoagulation was stopped and an IVC filter was placed at that time.  She has a history of malignant hypertension and has had a renal stent placed in February 2007.  She also has peripheral vascular disease with stent placements.  There is a history of spinal canal stenosis and iron deficiency anemia, currently on Procrit injections every two weeks done by Dr. Y. The patient denies any chest pain or any worsening of any shortness of breath.  There are no acute EKG changes or cardiac enzyme elevations.  She has had no stress test done following a bypass surgery.,PAST MEDICAL HISTORY,1.  Coronary artery disease, status post coronary artery bypass grafting.,2.  History of mitral regurgitation, unable to repair the valve.,3.  History of paroxysmal atrial fibrillation, on amiodarone.,4.  Gastroesophageal reflux disease.,5.  Hypertension.,6.  Hyperlipidemia.,7.  History of abdominal aortic aneurysm.,8.  Carotid artery disease, mild-to-moderate on recent carotid ultrasound.,9.  Peripheral vascular disease.,10.  Hypothyroidism.,11.  Pulmonary embolism.,PAST SURGICAL HISTORY,1.  Coronary artery bypass grafting.,2.  Hysterectomy.,3.  IVC filter.,4.  Tonsillectomy and adenoidectomy.,5.  Cosmetic surgery to breast and abdomen.,HOME MEDICATIONS,1.  Aspirin 81 mg once a day.,2.  Klor-Con 10 mEq once a day.,3.  Lasix 40 mg once a day.,4.  Levothyroxine 125 mcg once a day.,5.  Lisinopril 20 mg once a day.,6.  Pacerone 200 mg once a day.,7.  Protonix 40 mg once a day.,8.  Toprol 50 mg once a day.,9.  Vitamin B once a day.,10.  Zetia 10 mg once a day.,11.  Zyrtec 10 mg once a day.,ALLERGIES:,  CODEINE, ERYTHROMYCIN, SULFA, VICODIN, AND ZOCOR.,REVIEW OF SYSTEMS,CONSTITUTIONAL:  The patient denies any fevers, chills, recent weight gain or weight loss.  She has had abdominal symptoms with diarrhea.,EYES:  Decreased visual acuity.,ENT:  Sinus drainage.,CARDIOVASCULAR:  As described above.  Denies any chest pains.,RESPIRATORY:  He has chronic shortness of breath.  No cough or sputum production.,GI:  History of reflux symptoms.,GU:  No history of dysuria or hematuria.,ENDOCRINE:  No history of diabetes.,MUSCULOSKELETAL:  Denies arthritis, but has leg pain.,SKIN:  No history of rash.,PSYCHIATRIC:  No history of anxiety or depression.
---
DESCRIPTION: Patient with a history of coronary artery disease, status post coronary artery bypass grafting presented to the emergency room following a syncopal episode.

The situation involves a 78-year-old patient with multiple severe and chronic medical conditions, including coronary artery disease, previous coronary artery bypass grafting, history of pulmonary embolism, and malignant hypertension. She experienced a syncopal episode, suggesting the possibility of a serious underlying cardiac or vascular issue that needs urgent assessment to prevent potential life-threatening complications. Given her medical history and the presentation in the emergency room, this represents a high-stakes situation, as timely diagnosis and management are critical to prevent further complications or deterioration of her health condition.


Medical Specialty: Radiology
Sample Name: Dobutamine Stress Test - 1

DOBUTAMINE STRESS ECHOCARDIOGRAM,REASON FOR EXAM: , Chest discomfort, evaluation for coronary artery disease.,PROCEDURE IN DETAIL: , The patient was brought to the cardiac center.  Cardiac images at rest were obtained in the parasternal long and short axis, apical four and apical two views followed by starting with a dobutamine drip in the usual fashion at 10 mcg/kg per minute for low dose, increased every 2 to 3 minutes by 10 mcg/kg per minute.  The patient maximized at 30 mcg/kg per minute.  Images were obtained at that level after adding 0.7 mg of atropine to reach maximal heart rate of 145.  Maximal images were obtained in the same windows of parasternal long and short axis, apical four and apical two windows.,Wall motion assessed at all levels as well as at recovery.,The patient got nauseated, had some mild shortness of breath.  No angina during the procedure and the maximal amount of dobutamine was 30 mcg/kg per minute.,The resting heart rate was 78 with the resting blood pressure 186/98.  Heart rate reduced by the vasodilator effects of dobutamine to 130/80.  Maximal heart rate achieved was 145, which is 85% of age-predicted heart rate.,The EKG at rest showed sinus rhythm with no ST-T wave depression suggestive of ischemia or injury.  Incomplete right bundle-branch block was seen.  The maximal stress test EKG showed sinus tachycardia.  There was subtle upsloping ST depression in III and aVF, which is a normal response to the tachycardia with dobutamine, but no significant depression suggestive of ischemia and no ST elevation seen.,No ventricular tachycardia or ventricular ectopy seen during the test.  The heart rate recovered in a normal fashion after using metoprolol 5 mg.,The heart images were somewhat suboptimal to evaluate because of obesity and some problems with the short axis windows mainly at peak exercise.,The EF at rest appeared to be normal at 55 to 60 with normal wall motion including anterior, anteroseptal, inferior, lateral, and septal walls at low dose.  All walls mentioned were augmented in a normal fashion.  At maximum dose, all walls were augmented on all views except for the short axis was foreshortened, was uncertain about the anterolateral wall at peak exercise; however, of the other views, the lateral wall was showing normal thickening and normal augmentation.  EF improved to about 70%.,The wall motion score was unchanged.,IMPRESSION:,1.  Maximal dobutamine stress echocardiogram test achieving more than 85% of age-predicted heart rate.,2.  Negative EKG criteria for ischemia.,3.  Normal augmentation at low and maximum stress test with some uncertainty about the anterolateral wall in peak exercise only on the short axis view.  This is considered the negative dobutamine stress echocardiogram test, medical management.
---
DESCRIPTION: Dobutamine Stress Echocardiogram.  Chest discomfort, evaluation for coronary artery disease.  Maximal dobutamine stress echocardiogram test achieving more than 85% of age-predicted heart rate.  Negative EKG criteria for ischemia.

radiology, chest discomfort, coronary artery disease, predicted heart rate, dobutamine stress echocardiogram, anterolateral wall, echocardiogram test, wall motion, stress echocardiogram, short axis, dobutamine stress, heart rate, dobutamine, stress, ekg, echocardiogram, artery, ischemia, heart

A Dobutamine Stress Test is designed to evaluate coronary artery disease by examining the heart's function under stress. While the test itself involves potential risks, including increased heart rate and blood pressure, the results in this scenario show no significant indications of ischemia or heart abnormalities, with the test deemed negative. Given the negative results and the absence of critical findings, the situation's overall stakes are moderate as it pertains to routine testing rather than an emergency or serious condition.


Medical Specialty: Gastroenterology
Sample Name: Rectal Bleeding - 1-year-old

HISTORY OF PRESENT ILLNESS:,  This is a 1-year-old male patient who was admitted on 12/23/2007 with a history of rectal bleeding.  He was doing well until about 2 days prior to admission and when he passes hard stools, there was bright red blood in the stool.  He had one more episode that day of stool; the stool was hard with blood in it.  Then, he had one episode of rectal bleeding yesterday and again one stool today, which was soft and consistent with dark red blood in it.  No history of fever, no diarrhea, no history of easy bruising.  Excessive bleeding from minor cut.  He has been slightly fussy.,PAST MEDICAL HISTORY:  ,Nothing significant.,PREGNANCY DELIVERY AND NURSERY COURSE: , He was born full term without complications.,PAST SURGICAL HISTORY: , None.,SIGNIFICANT ILLNESS AND REVIEW OF SYSTEMS: , Negative for heart disease, lung disease, history of cancer, blood pressure problems, or bleeding problems.,DIET:,  Regular table food, 24 ounces of regular milk.  He is n.p.o. now.,TRAVEL HISTORY: , Negative.,IMMUNIZATION: , Up-to-date.,ALLERGIES: , None.,MEDICATIONS: , None, but he is on IV Zantac now.,SOCIAL HISTORY: , He lives with parents and siblings.,FAMILY HISTORY:,  Nothing significant.,LABORATORY EVALUATION: , On 12/24/2007, WBC 8.4, hemoglobin 7.6, hematocrit 23.2 and platelets 314,000.  Sodium 135, potassium 4.7, chloride 110, CO2 20, BUN 6 and creatinine 0.3.  Albumin 3.3.  AST 56 and ALT 26.  CRP less than 0.3.  Stool rate is still negative.,DIAGNOSTIC DATA: , CT scan of the abdomen was read as normal.,PHYSICAL EXAMINATION:  ,VITAL SIGNS:  Temperature 99.5 degrees Fahrenheit, pulse 142 per minute and respirations 28 per minute.  Weight 9.6 kilogram.,GENERAL:  He is alert and active child in no apparent distress.,HEENT:  Atraumatic and normocephalic.  Pupils are equal, round and reactive to light.  Extraocular movements, conjunctivae and sclerae fair.  Nasal mucosa pink and moist.  Pharynx is clear.,NECK:  Supple without thyromegaly or masses.,LUNGS:  Good air entry bilaterally.  No rales or wheezing.,ABDOMEN:  Soft and nondistended.  Bowel sounds positive.  No mass palpable.,GENITALIA:  Normal male.,RECTAL:  Deferred, but there was no perianal lesion.,MUSCULOSKELETAL:  Full range of movement.  No edema.  No cyanosis.,CNS:  Alert, active and playful.,IMPRESSION: , A 1-year-old male patient with history of rectal bleeding.  Possibilities include Meckel's diverticulum, polyp, infection and vascular malformation.,PLAN:,  To proceed with Meckel scan today.  If Meckel scan is negative, we will consider upper endoscopy and colonoscopy.  We will start colon clean out if Meckel scan is negative.  We will send his stool for C. diff toxin, culture, blood for RAST test for cow milk, soy, wheat and egg.  Monitor hemoglobin.
---
DESCRIPTION: Pediatric Gastroenterology - Rectal Bleeding Consult.

The situation involves a 1-year-old child with rectal bleeding, which requires careful medical evaluation and management. While it is not immediately life-threatening, rectal bleeding in such a young patient can indicate serious conditions like Meckel's diverticulum or a potential bleeding disorder. Therefore, prompt and thorough investigation is crucial to determine the underlying cause and prevent any complications. The stakes are higher because the patient is very young and the cause of bleeding is yet unknown, requiring immediate attention from the medical team.


Medical Specialty: Surgery
Sample Name: Laparoscopic Cholecystectomy - 5

PREOPERATIVE DIAGNOSIS: , Biliary colic.
---
DESCRIPTION: Biliary colic.   Laparoscopic cholecystectomy.  Laparoscopic examination showed no injury from entry.  Marcaine was then injected just subxiphoid, and a 5-mm port was placed under direct visualization for the laparoscope.

surgery, veress needle, gallbladder, laparoscope, laparoscopic examination, endotracheal intubation, laparoscopic cholecystectomy, biliary colic, abdomen, cholecystectomy, endotracheal, umbilicus, laparoscopic,

A laparoscopic cholecystectomy, a common surgical procedure to remove the gallbladder, often due to biliary colic (pain from gallstones). Although it's a routine surgery with a high success rate, it is still an invasive procedure with potential risks, including injury to bile ducts or other organs. The overall stakes are moderate owing to the potential for complications, though less than open surgeries. Success contributes substantially to patient well-being by alleviating symptoms.


Medical Specialty: Radiology
Sample Name: CT Lumbar Spine

EXAM:,  Noncontrast CT scan of the lumbar spine,REASON FOR EXAM: , Left lower extremity muscle spasm.,COMPARISONS: , None.,FINDINGS: , Transaxial thin slice CT images of the lumbar spine were obtained with sagittal and coronal reconstructions on emergency basis, as requested.,No abnormal paraspinal masses are identified.,There are sclerotic changes with anterior effusion of the sacroiliac joints bilaterally.,There is marked intervertebral disk space narrowing at the L5-S1 level with intervertebral disk vacuum phenomenon and advanced endplate degenerative changes.  Posterior disk osteophyte complex is present, most marked in the left paracentral to lateral region extending into the lateral recess on the left.  This most likely will affect the S1 nerve root on the left.  There are posterior hypertrophic changes extending into the neural foramina bilaterally inferiorly.  There is mild neural foraminal stenosis present.  Small amount of extruded disk vacuum phenomenon is present on the left in the region of the exiting nerve root.  There is facet sclerosis bilaterally.  Mild lateral recess stenosis just on the right, there is prominent anterior spondylosis.,At the L4-5 level, mild bilateral facet arthrosis is present.  There is broad based posterior annular disk bulging or protrusion, which mildly effaces the anterior aspect of the thecal sac and extends into the inferior aspect of the neural foramina bilaterally.  No moderate or high-grade central canal or neural foraminal stenosis is identified.,At the L3-4 level anterior spondylosis is present.  There are endplate degenerative changes with mild posterior annular disk bulging, but no evidence of moderate or high-grade central canal or neural foraminal stenosis.,At the L2-3 level, there is mild bilateral ligamentum flavum hypertrophy.  Mild posterior annular disk bulging is present without evidence of moderate or high-grade central canal or neural foraminal stenosis.,At the T12-L1 and L1-2 levels, there is no evidence of herniated disk protrusion, central canal, or neural foraminal stenosis.,There is arteriosclerotic vascular calcification of the abdominal aorta and iliac arteries without evidence of aneurysm or dilatation.  No bony destructive changes or acute fractures are identified.,CONCLUSIONS:,1. Advanced degenerative disk disease at the L5-S1 level.,2. Probable chronic asymmetric herniated disk protrusion with peripheral calcification at the L5-S1 level, laterally in the left paracentral region extending into the lateral recess causing lateral recess stenosis.,3. Mild bilateral neural foraminal stenosis at the L5-S1 level.,4. Posterior disk bulging at the L2-3, L3-4, and L4-5 levels without evidence of moderate or high-grade central canal stenosis.,5. Facet arthrosis to the lower lumbar spine.,6. Arteriosclerotic vascular disease.
---
DESCRIPTION: Noncontrast CT scan of the lumbar spine.  Left lower extremity muscle spasm.  Transaxial thin slice CT images of the lumbar spine were obtained with sagittal and coronal reconstructions on emergency basis, as requested.

radiology, noncontrast ct scan, lower extremity muscle spasm, neural foraminal stenosis, lumbar spine, spine, disk, lumbar, ct, intervertebral, canal, foraminal, noncontrast, stenosis,

The CT scan reveals advanced degenerative conditions and possible nerve involvement, which could be affecting the patient's quality of life, particularly with the left lower extremity muscle spasm noted. The potential impact on the S1 nerve root and mild foraminal stenosis could be significant for the patient’s mobility and pain levels. However, while it's medically important, it is not immediately life-threatening. The condition seems chronic rather than acute, and while it might require timely intervention to prevent further complications or alleviate symptoms, it is not a critical, life-or-death situation.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Cardiac Consultation - 5

REASON FOR REFERRAL: , Cardiac evaluation and treatment in a patient who came in the hospital with abdominal pain.,HISTORY:,  This is a 77-year-old white female patient whom I have known for the last about a year or so who has underlying multiple medical problems including hypertension, hyperlipidemia, diabetes mellitus, coronary artery disease status post aortocoronary bypass surgery about eight years ago at Halifax Medical Center where she had triple vessel bypass surgery with left internal mammary artery to the left anterior descending artery, saphenous vein graft to the left circumflex and right coronary arteries.  Since then, she has generally done well.  She used to be seeing another cardiologist and apparently she had a stress test in September 2008 and she was otherwise cardiac catheterization and coronary angiography, but the patient declined to have one done and since then she has been on medical therapy.,The patient had been on medical therapy at home and generally doing well.  Recently, she had no leg swelling, undue exertional dyspnea, orthopnea, or paroxysmal nocturnal dyspnea.  She denies any rest or exertional chest discomfort.  Yesterday evening, she had her dinner and she was sitting around and she felt discomfort in the chest at about 7:00 p.m.  The discomfort was a crampy pain in the left lower quadrant area, which seemed to radiating to the center of the abdomen and to the right side and it was off and on lasting for a few minutes at a time and then subsiding.  Later on she was nauseous, but she did not have any vomiting.  She denied any diarrhea.  No history of fever or chills.  Since the pain seemed to persist, the patient came to the hospital emergency room at 11:35 p.m. where she was seen and admitted for the same.  She was given morphine, Zofran, Demerol, another Zofran, and Reglan as well as Demerol again and she was given intravenous fluids.  Subsequently, her pain finally went away and she does not have any pain since about 7:00 a.m. this morning.  The patient was admitted however for further workup and treatment.  At the time of my examination this afternoon, the patient is sitting, lying in bed and comfortable and has no abdominal pain of any kind.  She has not been fed any food, however.  The patient also had had pelvis and abdominal CT scan performed, which has been described to be partial small bowel obstruction, internal hernia, volvulus or adhesion most likely in the left flank area.  The patient has had left nephrectomy and splenectomy, which has been described.  A 1.5-mm solid mass is described to be in the lower pole of the kidney.  The patient also has been described to have diverticulosis without diverticulitis on this finding.,Currently however, the patient has no clinical symptoms according to her.,PAST MEDICAL HISTORY:,  She has had hypertension and hyperlipidemia for the last 15 years, diabetes mellitus for the last eight years, and coronary artery disease for last about eight years or so.  She had a chest and back pain about eight years ago for about two weeks and then subsequently she was reported to be evaluated.  She has a small myocardial infarction and then she was under the care of Dr. A and she had aortocoronary bypass surgery at Halifax Medical Center by Dr. B, which was a three-vessel bypass surgery with left internal mammary artery to the left descending artery and saphenous vein graft to the left circumflex and distal right coronary artery respectively.,She had had nuclear stress test with Dr. C on September 3, 2008, which was described to be abnormal with ischemic defects, but I do not think the patient had any further cardiac catheterization and coronary angiography after that.  She has been treated medically.,This patient also had an admission to this hospital in May 2008 also for partial small bowel obstruction and cholelithiasis and sigmoid diverticulosis.  She was described to have had a hemorrhagic cyst of the right kidney.  She has mild arthritis for the last 10 or 15 years.  She has a history of GERD for the last 20 years, and she also has a history of peptic ulcer disease in the duodenum, but never had any bleeding.  She has a history of diverticulosis as mentioned.  No history of TIA or CVA.  She has one kidney.  She was in a car accident in 1978 and afterwards she had to have left nephrectomy as well as splenectomy because of rupture.  The patient has a history of pulmonary embolism once about eight years ago after her aortocoronary bypass surgery.  She describes this to be a clot on left lung.  I am not sure if she had any long-term treatment, however.,In the past, the patient had aortocoronary bypass surgery in 2003 and incisional hernia surgery in 1979 as well as hysterectomy in 1979 and she had splenectomy and nephrectomy as described in 1978.,FAMILY HISTORY: , Her father died at age of 65 of massive heart attack and mother died at age of 62 of cancer.  She had a one brother who died of massive heart attack in his 50s, a brother died at the age of 47 of cancer, and another brother died in his 60s of possible rupture of appendix.,SOCIAL HISTORY: , The patient is a widow.  She lives alone.  She does have three daughters, two of them live in Georgia and one lives in Tennessee.  She did smoke in the past up to one to one and a half packs of cigarettes per day for about 10 years, but she quit long time ago.  She never drank any alcohol.  She likes to drink one or two cups of tea in a day.,ALLERGIES: , PAXIL.,MEDICATIONS:,  Her home medications prior to coming in include some of the following medications, although the exact list is not available in the chart at this stage, but they have been on glyburide, Januvia, lisinopril, metformin, metoprolol, simvastatin, ranitidine, meloxicam, and furosemide.,REVIEW OF SYSTEMS:,  Appetite is good.  She sleeps good at night.  She has no headaches and she has mild joint pains from arthritis.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Pulse 90 per minute and regular, blood pressure 140/90 mmHg, respirations 18, and temperature of 98.5 degree Fahrenheit.  Moderate obesity is present.,CARDIAC:  Carotid upstroke is slightly diminished, but no clear bruit heard.,LUNGS:  Slightly decreased air entry at both bases.  No rales or rhonchi heard.,CARDIOVASCULAR:  PMI in the left fifth intercostal space in the midclavicular line.  Regular heart rhythm.  S1 and S2 normal.  S4 is present.  No S3 heard.  Short ejection systolic murmur grade I/VI is present at the left lower sternal border of the apex, peaking in LV systole, no diastolic murmur heard.,ABDOMEN:  Soft, obese, no tenderness, no masses felt.  Bowel sounds are present.,EXTREMITIES:  Bilateral trace edema.  The extremities are heavy.  There is no pitting at this stage.  No clubbing or cyanosis.  Distal pulses are fair.,CENTRAL NERVOUS SYSTEM:  Without any obvious focal deficits.,LABORATORY DATA: , Includes an electrocardiogram, which shows normal sinus rhythm, left atrial enlargement, and right bundle branch block.  This is overall unchanged compared to previous electrocardiogram, which also has the same present.  Nuclear stress test from 2008 was described to show ejection fraction of 49% and inferior and posterolateral ischemia.  Otherwise, laboratory data includes on this patient at this stage WBC 18.3, hemoglobin 15.5, hematocrit is 47.1, and platelet count is 326,000.  Electrolytes, sodium 137, potassium 5.2, chloride 101, CO2 27, BUN 34, creatinine 1.2, calcium 9.5, and magnesium 1.7.  AST and ALT are normal.  Albumin is 4.1.  Lipase and amylase are normal.  INR is 0.92.  Urinalysis is relatively unremarkable except for trace protein.  Chest x-ray has been described to show elevated left hemidiaphragm and median sternotomy sutures.  No infiltrates seen.  Abdomen and pelvis CAT scan findings are as described before with suggestion of partial small bowel obstruction and internal hernia.  Volvulus or adhesions have been considered.  Left nephrectomy and splenectomy demonstrated right kidney has a 1.5 cm solid mass at the lower pole suspicious for neoplasm according to the radiologist's description and there is diverticulosis.,IMPRESSION:,1.  Coronary artery disease and prior aortocoronary bypass surgery, currently clinically the patient without any angina.,2.  Possible small old myocardial infarction.,3.  Hypertension with hypertensive cardiovascular disease.,4.  Non-insulin-dependent diabetes mellitus.,5.  Moderate obesity.,6.  Hyperlipidemia.,7.  Chronic non-pitting leg edema.,8.  Arthritis.,9.  GERD and positive history of peptic ulcer disease.,CONCLUSION:,1.  Past left nephrectomy and splenectomy after an accident and injury and rupture of the spleen.,2.  Abnormal nuclear stress test in September 2008, but no further cardiac studies performed, such as cardiac catheterization.,3.  Lower left quadrant pain, which could be due to diverticulosis.,4.  Diverticulosis and partial bowel obstruction.,RECOMMENDATION:,1.  At this stage, the patient's cardiac medication should be continued if the patient is allowed p.o. intake.
---
DESCRIPTION: Cardiac evaluation and treatment in a patient who came in the hospital with abdominal pain.

The scenario involves a 77-year-old female with a complex medical history including coronary artery disease, a history of bypass surgery, potential bowel obstruction, and diverticulosis, among other conditions. Despite the patient's current stability, her medical history suggests potential complications such as cardiac events or worsening of bowel obstruction, both of which could be life-threatening. This makes the situation moderately high-stakes due to the potential for rapid deterioration if not carefully managed.


Medical Specialty: Gastroenterology
Sample Name: Gagging - 3-year-old

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

gastroenterology, g-tube, peho syndrome, tube site, gagging, constipation, endoscopy, peho, hemoglobin, hematocrit, intubated, bleeding, blood, fundoplication, tube,

This situation involves a 3-year-old patient with a complex medical history, including PEHO syndrome, G-tube complications, progressive encephalopathy, and coagulopathy. The child is currently intubated and has bleeding from the G-tube site, which necessitates urgent medical interventions such as vitamin K administration, fresh frozen plasma, blood transfusion, and possibly an upper endoscopy. The child's vitals also indicate distress, given the high pulse and respiration rates. The complexity and severity of the child's condition, alongside the potential for life-threatening complications due to bleeding and coagulopathy, make this a high-stakes situation. These factors indicate that timely and effective medical interventions are crucial to the child's outcome.


Medical Specialty: Neurology
Sample Name: EEG

DIAGNOSIS:,  Possible cerebrovascular accident.,DESCRIPTION: , The EEG was obtained using 21 electrodes placed in scalp-to-scalp and scalp-to-vertex montages.  The background activity appears to consist of fairly organized somewhat pleomorphic low to occasional medium amplitude of 7-8 cycle per second activity and was seen mostly posteriorly bilaterally symmetrically.  A large amount of movement artifacts and electromyographic effects were noted intermixed throughout the recording session.  Transient periods of drowsiness occurred naturally producing irregular 5-7 cycle per second activity mostly over the anterior regions.  Hyperventilation was not performed.  No epileptiform activity or any definite lateralizing findings were seen.,IMPRESSION: , Mildly abnormal study.  The findings are suggestive of a generalized cerebral disorder.  Due to the abundant amount of movement artifacts, any lateralizing findings, if any cannot be well appreciated.  Clinical correlation is recommended.
---
DESCRIPTION: Possible cerebrovascular accident.  The EEG was obtained using 21 electrodes placed in scalp-to-scalp and scalp-to-vertex montages.

neurology, scalp-to-scalp, scalp-to-vertex, montages, electrodes, amplitude, epileptiform activity, cerebrovascular accident, eegNOTE

The diagnosis of a possible cerebrovascular accident (CVA), or stroke, is inherently high-stakes because it involves potential brain damage and immediate health risks to the patient. The EEG findings in this case suggest a generalized cerebral disorder, and even though the study is mildly abnormal, the interpretation must be considered along with clinical symptoms. The presence of movement artifacts complicates the interpretation, possibly obscuring lateralizing signs that could help identify the affected brain area. Immediate and appropriate medical attention is crucial to confirm the diagnosis and manage patient care effectively, hence making this a high-stakes situation.


Medical Specialty: Obstetrics / Gynecology
Sample Name: TAH & BSO

PREOPERATIVE DIAGNOSES:,1.  Chronic pelvic pain.,2.  Dysmenorrhea.,3.  Dyspareunia.,4.  Endometriosis.,5.  Enlarged uterus.,6.  Menorrhagia.,POSTOPERATIVE DIAGNOSES:,1.  Chronic pelvic pain.,2.  Dysmenorrhea.,3.  Dyspareunia.,4.  Endometriosis.,5.  Enlarged uterus.,6.  Menorrhagia.,PROCEDURE: , Total abdominal hysterectomy and bilateral salpingo-oophorectomy.,ESTIMATED BLOOD LOSS: , Less than 100 mL.,DRAINS: , Foley.,ANESTHESIA:,  General.,This 28-year-old white female who presented to undergo TAH-BSO secondary to chronic pelvic pain and a diagnosis of endometriosis.,At the time of the procedure, once entering into the abdominal cavity, there was no gross evidence of abnormalities of the uterus, ovaries or fallopian tube.  All endometriosis had been identified laparoscopically from a previous surgery.  At the time of the surgery, all the tissue was quite thick and difficult to cut as well around the bladder flap and the uterus itself.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room and placed in supine position, at which time general form of anesthesia was administered by the anesthesia department.  The patient was then prepped and draped in the usual fashion for a low transverse incision.  Approximately two fingerbreadths above the pubic symphysis, a first knife was used to make a low transverse incision.  This was extended down to the level of the fascia.  The fascia was nicked in the center and extended in a transverse fashion.  The edges of the fascia were grasped with Kocher.  Both blunt and sharp dissection both caudally and cephalic was then completed consistent with Pfannenstiel technique.  The abdominal rectus muscle was divided in the midline and extended in a vertical fashion.  Perineum was entered at the high point and extended in a vertical fashion as well.  An O'Connor-O'Sullivan retractor was put in place on either side.  A bladder blade was put in place as well.  Uterus was grasped with a double-tooth tenaculum and large and small colon were packed away cephalically and held in place with free wet lap packs and a superior blade.  The bladder flap was released with Metzenbaum scissors and then dissected away caudally.  EndoGIA were placed down both sides of the uterus in two bites on each side with the staples reinforced with a medium Endoclip.  Two Heaney were placed on either side of the uterus at the level of cardinal ligaments.  These were sharply incised and both pedicles were tied off with 1 Vicryl suture.  Two _____ were placed from either side of the uterus at the level just inferior to the cervix across the superior part of the vaginal vault.  A long sharp knife was used to transect the uterus at the level of Merz forceps and the uterus and cervix were removed intact.  From there, the corners of the vaginal cuff were reinforced with figure-of-eight stitches.  Betadine soaked sponge was placed in the vaginal vault and a continuous locking stitch of 0 Vicryl was used to re-approximate the edges with a second layer used to reinforce the first.  Bladder flap was created with the use of 3-0 Vicryl and Gelfoam was placed underneath.  The EndoGIA was used to transect both the fallopian tube and ovaries at the infundibulopelvic ligament and each one was reinforced with medium clips.  The entire area was then re-peritonized and copious amounts of saline were used to irrigate the pelvic cavity.  Once this was completed, Gelfoam was placed into the cul-de-sac and the O'Connor-O'Sullivan retractor was removed as well as all the wet lap pack.  Edges of the peritoneum were grasped in 3 quadrants with hemostat and a continuous locking stitch of 2-0 Vicryl was used to re-approximate the peritoneum as well as abdominal rectus muscle.  The edges of the fascia were grasped at both corners and a continuous locking stitch of 1 Vicryl was used to re-approximate the fascia with overlapping in the center.  The subcutaneous tissue was irrigated.  Cautery was used to create adequate hemostasis and 3-0 Vicryl was used to re-approximate the tissue and the skin edges were re-approximated with sterile staples.  Sterile dressing was applied and Betadine soaked sponge was removed from the vaginal vault and the vaginal vault was wiped clean of any remaining blood.  The patient was taken to recovery room in stable condition.  Instrument count, needle count, and sponge counts were all correct.
---
DESCRIPTION: Total abdominal hysterectomy and bilateral salpingo-oophorectomy.

obstetrics / gynecology, tah, bso, total abdominal hysterectomy, bilateral salpingo-oophorectomy, hysterectomy, pelvic pai, dysmenorrhea, dyspareunia, endometriosis, uterus, menorrhagia, betadine soaked sponge, bladder flap, vaginal vault, abdominal, fascia, rectus,

The situation involves a major surgical procedure, a Total Abdominal Hysterectomy and Bilateral Salpingo-Oophorectomy (TAH-BSO), in a young woman with a complex medical history, including chronic pelvic pain and endometriosis. This type of surgery has significant implications for the patient's reproductive and hormonal health and can impact her overall well-being. The stakes are high due to the complexity of the procedure, the potential for complications, and the lasting effect on the patient's health, including infertility and surgical menopause. Ensuring the procedure is executed correctly and that the patient's recovery is monitored and managed well is crucial.


Medical Specialty: Surgery
Sample Name: Circumcision

PREOPERATIVE DIAGNOSIS:,  Phimosis.,POSTOPERATIVE DIAGNOSES:,  Phimosis.,OPERATIONS:,  Circumcision.,ANESTHESIA: , LMA.,EBL:,  Minimal.,FLUIDS: , Crystalloid.,BRIEF HISTORY: , This is a 3-year-old male, who was referred to us from Dr. X's office with phimosis.  The patient had spraying of urine and ballooning of the foreskin with voiding.  The urine seemed to have collected underneath the foreskin and then would slowly drip out.  Options such as dorsal slit, circumcision, watchful waiting by gently pulling the foreskin back were discussed.  Risk of anesthesia, bleeding, infection, pain, scarring, and expected complications were discussed.  The patient's family understood all the complications and wanted to proceed with the procedure.  Consent was obtained using interpreter.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the OR and anesthesia was applied.  The patient was placed in supine position.  The patient was prepped and draped in usual sterile fashion.  All the penile adhesions were released prior to the prepping.  The extra foreskin was marked off, 1 x 3 Gamco clamp was used.  Hemostasis was obtained after removing the extra foreskin using the Gamco clamp.,Using 5-0 Monocryl, 4 quadrant stitches were placed and horizontal mattress suturing was done.  There was excellent hemostasis.  Dermabond was applied.  The patient was brought to recovery at the end of the procedure in stable condition.
---
DESCRIPTION: The patient had spraying of urine and ballooning of the foreskin with voiding.

surgery, ballooning of the foreskin, spraying of urine, gamco clamp, spraying, ballooning, circumcision, urine, phimosis, foreskin

The situation described involves a surgical procedure for a 3-year-old child to treat phimosis, which can impact the child's urination. The procedure has potential risks such as anesthesia-related complications, bleeding, and infection, common in surgical settings. While these risks exist, the condition itself is typically not life-threatening, and circumcision is a common and routine procedure. The stakes are moderate because surgery in young children requires careful risk management, but the procedure's routine nature and the minimal complications described indicate lower stakes compared to more complex surgeries or life-threatening conditions.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Double Lumen Port Inserstion

PREOPERATIVE DIAGNOSIS:,  Metastatic glossal carcinoma, needing chemotherapy and a port.,POSTOPERATIVE DIAGNOSIS: , Metastatic glossal carcinoma, needing chemotherapy and a port.,PROCEDURES,1.  Open exploration of the left subclavian/axillary vein.,2.  Insertion of a double lumen port through the left femoral vein, radiological guidance.,DESCRIPTION OF PROCEDURE: , After obtaining the informed consent, the patient was electively taken to the operating room, where he underwent a general anesthetic through his tracheostomy.  The left deltopectoral and cervical areas were prepped and draped in the usual fashion.  Local anesthetic was infiltrated in the area.  There was some evidence that surgical procedure had happened in the area nearby and also there was collateral venous circulation under the skin, which made us suspicious that may be __________, but at any rate I tried to cannulate it subcutaneously and I was unsuccessful.  Therefore, I proceeded to make an incision and was able to isolate the vein, which would look very sclerotic.  I tried to cannulate it, but I could not advance the wire.,At that moment, I decided that there was no way we are going to put a port though that area.  I packed the incision and we prepped and redraped the patient including both groins.  Local anesthetic was infiltrated and then the left femoral vein was percutaneously cannulated without any difficulty.  The introducer was placed and then a wire and then the catheter of the double lumen port, which had been trimmed to position it near the heart.  It was done with radiological guidance.  Again, I was able to position the catheter in the junction of inferior vena cava and right atrium.  The catheter was looked upwards and the double lumen port was inserted subcutaneously towards the iliac area.  The port had been aspirated satisfactorily and irrigated with heparin solution.  The drain incision was closed in layers including subcuticular suture with Monocryl.  Then, we went up to the left shoulder and closed that incision in layers.  Dressings were applied.,The patient tolerated the procedure well and was sent back to recovery room in satisfactory condition.
---
DESCRIPTION: Insertion of a double lumen port through the left femoral vein, radiological guidance.  Open exploration of the left subclavian and axillary vein.  Metastatic glossal carcinoma, needing chemotherapy and a port.

cardiovascular / pulmonary, axillary, vein, subclavian, double lumen port, femoral vein, radiological guidance, glossal carcinoma, port, inserstion, femoral, radiological, metastatic, carcinoma, chemotherapy, anesthetic, catheter,

The procedure described involves the insertion of a double lumen port, which is necessary for administering chemotherapy to a patient with metastatic glossal carcinoma. This is a high-stakes situation due to several factors: it involves a patient with a serious and life-threatening condition (metastatic cancer), requires surgical intervention, and the insertion of a port is critical for ongoing chemotherapy treatment. However, it is a routine procedure for such medical needs, so while it is important, it does not involve emergency intervention. The complexity and the patient's underlying condition elevate the stakes but not to the maximum extent.


Medical Specialty: Consult - History and Phy.
Sample Name: Migraine without Aura - Consult

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

The situation describes a patient suffering from moderate to severe migraines without aura. While migraines can significantly affect quality of life, they are not typically immediately life-threatening. The patient does not exhibit symptoms that suggest a severe underlying neurological condition, and their health appears stable in other areas. Additionally, a treatment plan has been established with medication and lifestyle modifications. However, without effective management, the migraines could impact daily life, hence it is more than a low-stakes situation.


Medical Specialty: Gastroenterology
Sample Name: Gastroenterology - Letter

Sample Address,Re:  Mrs. Sample Patient,Dear Sample Doctor:,I had the pleasure of seeing your patient, Mrs. Sample Patient , in my office today.  Mrs. Sample Patient is a 48-year-old, African-American female with a past medical history of hypertension and glaucoma, who was referred to me to be evaluated for intermittent rectal bleeding.  The patient denies any weight loss, does have a good appetite, no nausea and no vomiting.,PAST MEDICAL HISTORY:,  Significant for hypertension and diabetes.,PAST SURGICAL HISTORY:,  The patient denies any past surgical history.,MEDICATIONS:,  The patient takes Cardizem CD 240-mg.  The patient also takes eye drops.,ALLERGIES:,  The patient denies any allergies.,SOCIAL HISTORY:,  The patient smokes about a pack a day for more than 25 years.  The patient drinks alcohol socially.,FAMILY HISTORY:,  Significant for hypertension and strokes.,REVIEW OF SYSTEMS:,  The patient does have a good appetite and no weight loss.  She does have intermittent rectal bleeding associated with irritation in the rectal area.  The patient denies any nausea, any vomiting, any night sweats, any fevers or any chills.,The patient denies any shortness of breath, any chest pain, any irregular heartbeat or chronic cough.,The patient is chronically constipated.,PHYSICAL EXAMINATION:,  This is a 48 year-old lady who is awake, alert and oriented x 3.  She does not seem to be in any acute distress.  Her vital signs are blood pressure is 130/70 with a heart rate of 75 and respirations of 16.  HEENT is normocephalic, atraumatic.  Sclerae are non-icteric.  Her neck is supple, no bruits, no lymph nodes.  Lungs are clear to auscultation bilaterally, no crackles, no rales and no wheezes.  The cardiovascular system has a regular rate and rhythm, no murmurs.  The abdomen is soft and non-tender.  Bowel sounds are positive and no organomegaly.  Extremities have no edema.,IMPRESSION:,  This is a 48-year-old female presenting with painless rectal bleeding not associated with any weight loss.  The patient is chronically constipated.,1.  Rule out colon cancer.,2.  Rule out colon polyps. ,3.  Rule out hemorrhoids, which is the most likely diagnosis.,RECOMMENDATIONS:,  Because of the patient's age, the patient will need to have a complete colonoscopy exam.,The patient will also need to have a CBC check and monitor.,The patient will be scheduled for the colonoscopy at Sample Hospital and the full report will be forwarded to your office.,Thank you very much for allowing me to participate in the care of your patient.,Sincerely yours,,Sample Doctor, MD
---
DESCRIPTION: Female with intermittent rectal bleeding, not associated with any weight loss.  The patient is chronically constipated.

This situation involves a patient with symptoms that require medical evaluation for potentially serious conditions such as colon cancer, polyps, or hemorrhoids. The patient is recommended for a colonoscopy, which is a standard procedure for ruling out these conditions. Given the potential seriousness of colon cancer, this situation is moderately high-stakes. However, the most likely diagnosis is hemorrhoids, which are less serious, so it's important but not extremely high-stakes.


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

Medical Specialty: Neurology
Sample Name: Electroencephalogram - 1

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

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

The situation involves the analysis of an electroencephalogram (EEG) report, used to assess brain activity. The report indicates an essentially normal EEG with no significant abnormalities. This situation is typically not high-stakes because the normal findings suggest no immediate neurological concerns, and the absence of critical abnormalities means no urgent medical intervention is necessary. However, since this analysis pertains to neurological health, it cannot be rated too low-stakes.


Medical Specialty: Orthopedic
Sample Name: MRI Shoulder - 5

EXAM:,MRI LEFT SHOULDER,CLINICAL:,This is a 26 year old with a history of instability. Examination was preformed on 12/20/2005.,FINDINGS:,There is supraspinatus tendinosis without a full-thickness tear, gap or fiber retraction and there is no muscular atrophy (series #105 images #4-6).,Normal infraspinatus and subscapularis tendons.,Normal long biceps tendon within the bicipital groove. There is medial subluxation of the tendon under the transverse humeral ligament, and there is tendinosis of the intracapsular portion of the tendon with partial tearing, but there is no complete tear or discontinuity. Biceps anchor is intact (series #105 images #4-7; series #102 images #10-22).,There is a very large Hill-Sachs fracture, involving almost the entire posterior half of the humeral head (series #102 images #13-19). This is associated with a large inferior bony Bankart lesion that measures approximately 15 x 18mm in AP and craniocaudal dimension with impaction and fragmentation (series #104 images #10-14; series #102 images #18-28). There is medial and inferior displacement of the fragment. There are multiple interarticular bodies, some of which may be osteochondromatous and some may be osseous measuring up to 8mm in diameter. (These are too numerous to count.) There is marked stretching, attenuation and areas of thickening of the inferior and middle glenohumeral ligaments, compatible with a chronic tear with scarring but there is no discontinuity or demonstrated HAGL lesion (series #105 images #5-10).,Normal superior glenohumeral ligament.,There is no SLAP tear.,Normal acromioclavicular joint without narrowing of the subacromial space.,Normal coracoacromial, coracohumeral and coracoclavicular ligaments.,There is fluid in the glenohumeral joint and biceps tendon sheath.,IMPRESSION:,There is a very large Hill-Sachs fracture involving most of the posterior half of the humeral head with an associated large and inferior and medial displaced osseous Bankart lesion.,There are multiple intraarticular bodies, and there is a partial tear of the inferior and middle glenohumeral ligaments.,There is medial subluxation of the long biceps tendon under the transverse humeral ligament with partial tearing of the intracapsular portion.,
---
DESCRIPTION: MRI left shoulder.

MRI left shoulder.

orthopedic, inferior and middle glenohumeral, biceps tendon, partial tearing, glenohumeral ligaments, mri, shoulder, ligament, ligaments, biceps, humeral, glenohumeral, tear, tendons

The findings from the MRI indicate a significant orthopedic injury, including a large Hill-Sachs fracture and a Bankart lesion, which are serious and could impact shoulder stability and function. However, it is not immediately life-threatening, and the described injuries, while requiring medical attention, are typically managed without urgency. Therefore, the situation is serious in terms of patient impact and future implications of joint function, but not immediately high-stakes in a critical, life-threatening sense.


Medical Specialty: Consult - History and Phy.
Sample Name: Prostate Adenocarcinoma - H&P

HISTORY OF PRESENT ILLNESS: , The patient is a 62-year old male with a Gleason score 8 adenocarcinoma of the prostate involving the left and right lobes.  He has a PSA of 3.1, with a prostate gland size of 41 grams.  This was initially found on rectal examination with a nodule on the right side of the prostate, showing enlargement relative to the left.  He has undergone evaluation with a bone scan that showed a right parietal lesion uptake and was seen by Dr. XXX and ultimately underwent an open biopsy that was not malignant.  Prior to this, he has also had a ProstaScint scan that was negative for any metastatic disease.  Again, he is being admitted to undergo a radical prostatectomy, the risks, benefits, and alternatives of which have been discussed, including that of bleeding, and a blood transfusion.,PAST MEDICAL HISTORY: , Coronary stenting.  History of high blood pressure, as well.  He has erectile dysfunction and has been treated with Viagra.,MEDICATIONS: , Lisinopril, Aspirin, Zocor, and Prilosec.,ALLERGIES:,  Penicillin.,SOCIAL HISTORY:,  He is not a smoker.  He does drink six beers a day.,REVIEW OF SYSTEMS: , Remarkable for his high blood pressure and drug allergies, but otherwise unremarkable, except for some obstructive urinary symptoms, with an AUA score of 19.,PHYSICAL EXAMINATION:,HEENT:  Examination unremarkable.,Breasts:  Examination deferred.,Chest:  Clear to auscultation.,Cardiac:  Regular rate and rhythm.,Abdomen:  Soft and nontender.  He has no hernias.,Genitourinary:  There is a normal-appearing phallus, prominence of the right side of prostate.,Extremities:  Examination unremarkable.,Neurologic:  Examination nonfocal.,IMPRESSION:,1.  Adenocarcinoma of the prostate.,2.  Erectile dysfunction.,PLAN:  ,The patient will undergo a bilateral pelvic lymphadenectomy and radical retropubic prostatectomy.  The risks, benefits, and alternatives of this have been discussed.  He understands and asks that I proceed ahead.  We also discussed bleeding and blood transfusions, and the risks, benefits and alternatives thereof.
---
DESCRIPTION: Adenocarcinoma of the prostate, Erectile dysfunction - History & Physical

consult - history and phy., gleason score, gleason, prostate gland, prostascint, retropubic prostatectomy, adenocarcinoma of the prostate, erectile dysfunction, adenocarcinoma, radical, prostatectomy, erectile, dysfunction, prostate,

The patient's situation involves a diagnosis of prostate adenocarcinoma with a high Gleason score, indicating an aggressive form of cancer. The patient is scheduled for a radical prostatectomy, a significant surgical procedure with potential risks such as bleeding. While not immediately life-threatening, it is a major health concern that requires serious attention. The ongoing treatment and its impact on his quality of life, along with the associated medical history such as coronary stenting and high blood pressure, further increase the stakes of the situation.


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.
---
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: ENT - Otolaryngology
Sample Name: Myringotomy/Tube Insertion - 3

PREOPERATIVE DIAGNOSES: ,1.  Chronic eustachian tube dysfunction.,2.  Retained right pressure equalization tube.,3.  Retracted left tympanic membrane.,4.  Dizziness.,POSTOPERATIVE DIAGNOSES:,1.  Chronic eustachian tube dysfunction.,2.  Retained right pressure equalization tube.,3.  Retracted left tympanic membrane.,4.  Dizziness.,PROCEDURE:,1.  Removal of the old right pressure equalizing tube with placement of a tube.  Tube used was Santa Barbara.,2.  Myringotomy with placement of a left pressure equalizing tube.  The tube used was Santa Barbara.,ANESTHESIA:,  General.,INDICATION: , This is a 98-year-old female whom I have known for several years.  She has a marginal hearing.  With the additional conductive loss secondary to the retraction of the tympanic membrane, her hearing aid and function deteriorated significantly.  So, we have kept sets of tubes in her ears at all times.  The major problem is that she has got small ear canals and a very sensitive external auditory canal; therefore it cannot tolerate even the wax cleaning in the clinic awake.,The patient was seen in the OR and tubes were placed.  There were no significant findings.,PROCEDURE IN DETAIL: , After obtaining informed consent from the patient, she was brought to the neurosensory OR, placed under general anesthesia.  Mask airway was used.  IV had already been started.,On the right side, we removed the old tube and then cleaned the cerumen and found that it was larger than the side of the tube in perfection or perforation in tympanic membrane in the anterior inferior quadrant.  In the same area, a small Santa Barbara tube was placed.  This T-tube was cut to 80% of its original length for comfort and then positioned to point straight out and treated.  Three drops of ciprofloxacin eyedrops was placed in the ear canal.,On the left side, the tympanic membrane adhered and it was retracted and has some myringosclerosis.  Anterior, inferior incision was made.  Tympanic membrane bounced back to neutral position.  A Santa Barbara tube was cut to the 80% of the original length and placed in the hole.  Ciprofloxacin drops were placed in the ear.  Procedure completed.,ESTIMATED BLOOD LOSS: , None.,COMPLICATION: , None.,SPECIMEN:,  None.,DISPOSITION:,  To PACU in a stable condition.
---
DESCRIPTION: Removal of the old right pressure equalizing tube.  Myringotomy with placement of a left pressure equalizing tube.

The described procedure involves minor ear surgery for issues like eustachian tube dysfunction, and retraction of the tympanic membrane in a 98-year-old patient. While any surgical procedure carries some risk, in this context it's relatively common and routine. Given the patient's age and the need for general anesthesia, there is a moderate level of stakes due to her vulnerability. Overall, myringotomy and pressure equalization tube placements are considered low-risk procedures, especially as no complications arose.


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

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

Bilateral open carpal tunnel release.

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

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


Medical Specialty: Surgery
Sample Name: Colonoscopy & Polypectomy - 1

PREOPERATIVE DIAGNOSIS:,  History of colitis.,POSTOPERATIVE DIAGNOSIS: , Small left colon polyp.,PROCEDURE PERFORMED: , Total colonoscopy and polypectomy.,ANESTHESIA:,  IV Versed 8 mg and 175 mcg of IV fentanyl.,CLINICAL HISTORY: , This patient had a tough time with colitis 10 years ago and has intermittent problems with bleeding.  He has been admitted to the hospital now for colonoscopy and polyp surveillance.,PROCEDURE:  ,The patient was prepped and draped in a left lateral decubitus position.  The flexible 165 cm CF video Olympus colonoscope was inserted through the anus and passed under TV-directed monitor through the area of the rectum, sigmoid colon, left colon, transverse colon, right colon, and cecum.  He had an excellent prep.  He had a 2-3 mm polyp in the left colon that was removed with a jumbo biopsy forceps.  He tolerated the procedure well.  There was no other evidence of any cancer, growth, tumor, colitis, or problems throughout the entire colon.  His exam that he had in 1997 showed a small amount of colitis at that time and he has had some intermittent symptoms since.  Representative pictures were taken throughout the entire exam.  There was no other evidence any problems.  On withdrawal of the scope, the same findings were noted.,FINAL IMPRESSION: , Small, left colon polyp in a patient with intermittent colitis-like symptoms and bleeding.
---
DESCRIPTION: Total colonoscopy and polypectomy

Total colonoscopy and polypectomy

surgery, anus, lateral decubitus position, colon, colonoscopy and polypectomy, total colonoscopy, colon polyp, colonoscopy, bleeding, colitis, polypectomy, intermittent,

The situation involves a surgical procedure, specifically a colonoscopy with polypectomy, which is used to diagnose and address potential polyps or abnormalities in the colon. The stakes for most colonoscopies, while important for early detection of issues like polyps, cancer, or other intestinal problems, are typically not extremely high-stakes unless complications occur. This case involves the removal of a small colon polyp in a patient with a history of colitis and intermittent bleeding, which are standard considerations for such procedures. Given that the procedure was completed without complications and no significant risks were identified, it is not an extremely high-stakes scenario from a surgical perspective, though it is crucial for ongoing monitoring and prevention.


Medical Specialty: Hematology - Oncology
Sample Name: Needle Localized Excision - Breast Neoplasm

PREOPERATIVE DIAGNOSIS: , Nonpalpable neoplasm, right breast.,POSTOPERATIVE DIAGNOSIS: , Deferred for Pathology.,PROCEDURE PERFORMED:  ,Needle localized wide excision of nonpalpable neoplasm, right breast.,SPECIMEN: , Mammography.,GROSS FINDINGS:  ,This 53-year-old Caucasian female who had a nonpalpable neoplasm detected by mammography in the right breast.  After excision of neoplasm, there was a separate 1 x 2 cm nodule palpated within the cavity.  This too was excised.,OPERATIVE PROCEDURE:  ,The patient was taken to the operating room, placed in supine position in the operating table.  Intravenous sedation was administered by the Anesthesia Department.  The Kopans wire was trimmed to an appropriate length.  The patient was sterilely prepped and draped in the usual manner.  Local anesthetic consisting of 1% lidocaine and 0.5% Marcaine was injected into the proposed line of incision.  A curvilinear circumareolar incision was then made with a #15 scalpel blade close to the wire.  The wire was stabilized and brought to protrude through the incision.  Skin flaps were then generated with electrocautery.  A generous core tissue was grasped with Allis forceps and excised with electrocautery.  Prior to complete excision, the superior margin was marked with a #2-0 Vicryl suture, which was tied and cut short.  The lateral margin was marked with a #2-0 Vicryl suture, which was tied and cut along.  The posterior margin was marked with a #2-0 Polydek suture, which was tied and cut.,The specimen was then completely excised and sent off the operative field as specimen where specimen mammography confirmed the excision of the mammographically detected neoplasm.  On palpation of the cavity, there was felt to be a second nodule further medial and this was grasped with an Allis forceps and excised with electrocautery and sent off the field as a separate specimen.  Hemostasis was obtained with electrocautery.  Good hemostasis was obtained.  The incision was closed in two layers.  The first layer consisting of a subcuticular inverted interrupted sutures of #4-0 undyed Vicryl.  The second layer consisted of Steri-Strips on the epidermis.  A pressure dressing of fluff, 4x4s, ABDs, and Elastic bandage was applied.  The patient tolerated the surgery well.
---
DESCRIPTION: Nonpalpable neoplasm, right breast.  Needle localized wide excision of nonpalpable neoplasm, right breast.

hematology - oncology, neoplasm, needle localized wide excision, needle localized, nonpalpable neoplasm, needle, incision, electrocautery, excision, breast

The situation involves a surgical procedure to excise a nonpalpable neoplasm from the breast, which is significant as it pertains to potential cancer diagnosis and treatment. The stakes are heightened given the possibility of the neoplasm being malignant, which can have serious implications for the patient's health and future treatment plans. Hematology-oncology deals with such cancers, making accurate excision and pathology reporting crucial. However, it is a planned procedure without immediate life-threatening complications reported during the surgery, so it is not at the extreme high end of the stakes scale.


Medical Specialty: Office Notes
Sample Name: Induction of Vaginal Delivery

DIAGNOSES,1.  Term pregnancy.,2.  Possible rupture of membranes, prolonged.,PROCEDURE:,  Induction of vaginal delivery of viable male, Apgars 8 and 9.,HOSPITAL COURSE:,  The patient is a 20-year-old female, gravida 4, para 0, who presented to the office.  She had small amount of leaking since last night.  On exam, she was positive Nitrazine, no ferning was noted.  On ultrasound, her AFI was about 4.7 cm.  Because of a variable cervix, oligohydramnios, and possible ruptured membranes, we recommended induction.,She was brought to the hospital and begun on Pitocin.  Once she was in her regular pattern, we ruptured her bag of water; fluid was clear.  She went rapidly to completion over the next hour and a half.  She then pushed for 2 hours delivering a viable male over an intact perineum in an OA presentation.  Upon delivery of the head, the anterior and posterior arms were delivered, and remainder of the baby without complications.  The baby was vigorous, moving all extremities.  The cord was clamped and cut.  The baby was handed off to mom with nurse present.  Apgars were 8 and 9.  Placenta was delivered spontaneously, intact.  Three-vessel cord with no retained placenta.  Estimated blood loss was about 150 mL.  There were no tears.
---
DESCRIPTION: Induction of vaginal delivery of viable male, Apgars 8 and 9.  Term pregnancy and oossible rupture of membranes, prolonged.

office notes, induction of vaginal delivery, vaginal delivery, viable male, pregnancy, placenta, vaginal, membranes, apgars

The scenario involves the induction of vaginal delivery, which can be considered high-stakes due to the potential risks involved in childbirth, both for the mother and the baby. Factors such as the possible rupture of membranes and the use of medication like Pitocin add complexity and potential risk. Despite this, the document indicates a positive outcome with no complications or tears and healthy Apgar scores for the newborn, which mitigates the stakes to some extent. However, the context of childbirth, especially with possible complications, inherently involves significant risk.


Medical Specialty: Surgery
Sample Name: Laminotomy & Microdissection

PREOPERATIVE DIAGNOSES:  ,1.  Fractured and retained lumbar subarachnoid spinal catheter.,2.  Pseudotumor cerebri (benign intracranial hypertension).,PROCEDURES:  ,1.  L1 laminotomy.,2.  Microdissection.,3.  Retrieval of foreign body (retained lumbar spinal catheter).,4.  Attempted insertion of new external lumbar drain.,5.  Fluoroscopy.,ANESTHESIA: , General.,HISTORY:  ,The patient had a lumbar subarachnoid drain placed yesterday.  All went well with the surgery.  The catheter stopped draining and on pulling back the catheter, it fractured and CT scan showed that the remaining fragment is deep to the lamina.  The patient continues to have right eye blindness and headaches, presumably from the pseudotumor cerebri.,DESCRIPTION OF PROCEDURE:  ,After induction of general anesthesia, the patient was placed prone on the operating room table resting on chest rolls.  Her face was resting in a pink foam headrest.  Extreme care was taken positioning her because she weighs 92 kg.  There was a lot of extra padding for her limbs and her limbs were positioned comfortably.  The arms were not hyperextended.  Great care was taken with positioning of the head and making sure there was no pressure on her eyes especially since she already has visual disturbance.  A Foley catheter was in place.  She received IV Cipro 400 mg because she is allergic to most antibiotics.,Fluoroscopy was used to locate the lower end of the fractured catheter and the skin was marked.  It was also marked where we would try to insert the new catheter at the L4 or L3 interspinous space.,The patient was then prepped and draped in a sterile manner.,A 7-cm incision was made over the L1 lamina.  The incision was carried down through the fascia all the way down to the spinous processes.  A self-retaining McCullough retractor was placed.  The laminae were quite deep.  The microscope was brought in and using the Midas Rex drill with the AM-8 bit and removing some of the spinous process of L1-L2 with double-action rongeurs, the laminotomy was then done using the drill and great care was taken and using a 2-mm rongeur, the last layer of lamina was removed exposing the epidural fat and dura.  The opening in the bone was 1.5 x 1.5 cm.,Occasionally, bipolar cautery was used for bleeding of epidural veins, but this cautery was kept to a minimum.,Under high magnification, the dura was opened with an 11 blade and microscissors.  At first, there was a linear incision vertically to the left of midline, and I then needed to make a horizontal incision more towards the right.  The upper aspect of the cauda equina was visualized and perhaps the lower end of the conus.  Microdissection under high magnification did not expose the catheter.  The fluoroscope was brought in 2 more times including getting a lateral view and the fluoroscope appeared to show that the catheter should be in this location.,I persisted with intensive microdissection and finally we could see the catheter deep to the nerves and I was able to pull it out with the microforceps.,The wound was irrigated with bacitracin irrigation.,At this point, I then attempted lumbar puncture by making a small incision with an 11 blade in the L4 interspinous space and then later in the L3 interspinous space and attempted to puncture the dural sac with the Tuohy needle.  Dr. Y also tried.  Despite using the fluoroscope and our best attempts, we were not able to convincingly puncture the lumbar subarachnoid space and so the attempted placement of the new lumbar catheter had to be abandoned.  It will be done at a later date.,I felt it was unsafe to place a new catheter at this existing laminotomy site because it was very high up near the conus.  The potential for complications involving her spinal cord was greater and we have already had a complication of the catheter now and I just did not think it was safe to put in this location.,Under high magnification, the dura was closed with #6-0 PDS interrupted sutures.,After the dura was closed, a piece of Gelfoam was placed over the dura.  The paraspinous muscles were closed with 0 Vicryl interrupted sutures.  The subcutaneous fascia was also closed with 0 Vicryl interrupted suture.  The subcutaneous layer was closed with #2-0 Vicryl interrupted suture and the skin with #4-0 Vicryl Rapide.  The 4-0 Vicryl Rapide sutures were also used at the lumbar puncture sites to close the skin.,The patient was then turned carefully on to her bed after sterile dressings were applied and then taken to the recovery room.  The patient tolerated procedure well.  No complications.  Sponge and needle counts correct.  Blood loss minimal, none replaced.  This procedure took 5 hours.  This case was also extremely difficult due to patient's size and the difficulty of locating the catheter deep to the cauda equina.
---
DESCRIPTION: L1 laminotomy, microdissection, retrieval of foreign body (retained lumbar spinal catheter), attempted insertion of new external lumbar drain, and fluoroscopy.

surgery, laminotomy, microdissection, lumbar spinal catheter, external lumbar drain, fluoroscopy, lumbar subarachnoid, spinal catheter, intracranial hypertension, vicryl interrupted sutures, lumbar, catheter,

The situation involves a complex surgical procedure with multiple steps, including a laminotomy, microdissection, and retrieval of a broken catheter fragment from near the spinal cord. Additionally, the case involves significant risks due to previous complications, patient size, and the location of the fracture near sensitive areas such as the cauda equina and conus medullaris. Also, there is a pre-existing condition of pseudotumor cerebri contributing to the critical nature of the surgery. Such surgeries inherently carry high stakes due to the potential for serious complications, including neurological damage.


Medical Specialty: Surgery
Sample Name: Colonoscopy - 14

PREPROCEDURE DIAGNOSIS: , History of colon polyps and partial colon resection, right colon.,POSTPROCEDURE DIAGNOSES:  ,1. Normal operative site.  ,2. Mild diverticulosis of the sigmoid colon.  ,3. Hemorrhoids.,PROCEDURE:  ,Total colonoscopy.,PROCEDURE IN DETAIL:  ,The patient is a 60-year-old of Dr. ABC's being evaluated for the above.  The patient also apparently had an x-ray done at the Hospital and it showed a dark spot, and because of this, a colonoscopy was felt to be needed.  She was prepped the night before and on the morning of the test with oral Fleet's, brought to the second floor and sedated with a total of 50 mg of Demerol and 3.75 mg of Versed IV push.  Digital rectal exam was done, unremarkable.  At that point, the Pentax video colonoscope was inserted.  The rectal vault appeared normal.  The sigmoid showed diverticula throughout, mild to moderate in nature.  The scope was then passed through the descending and transverse colon over to the hepatic flexure area and then the anastomosis site was visualized.  The scope was passed a short distance up the ileum, which appeared normal.  The scope was then withdrawn through the transverse, descending, sigmoid, and rectal vault area.  The scope was then retroflexed, and anal verge visualized showed some hemorrhoids.  The scope was then removed.  The patient tolerated the procedure well.,RECOMMENDATIONS:  ,Repeat colonoscopy in three years.
---
DESCRIPTION: Colonoscopy. History of colon polyps and partial colon resection, right colon.  Mild diverticulosis of the sigmoid colon.  Hemorrhoids.

surgery, partial colon resection, diverticulosis, colon polyps, rectal vault, colonoscopy, polyps, hemorrhoids, sigmoid

The situation described is about a routine colonoscopy procedure for a patient with a medical history involving colon polyps and partial colon resection. The procedure itself was undertaken due to a previously spotted dark spot on an x-ray, but the current assessment found normal operative sites, mild diverticulosis, and hemorrhoids. The procedure was tolerated well by the patient, and a repeat colonoscopy was recommended in three years. Given the routine nature of the follow-up and lack of immediate critical findings, this scenario is not high-stakes.


Medical Specialty: Neurology
Sample Name: MRI Brain - Toxoplasmosis

CC:, Lethargy.,HX:, This 28y/o RHM was admitted to a local hospital on 7/14/95 for marked lethargy. He had been complaining of intermittent headaches and was noted to have subtle changes in personality for two weeks prior to 7/14/95. On the morning of 7/14/95, his partner found him markedly lethargic and complaingin of abdominal pain and vomiting. He denied fevers, chills, sweats, cough, CP, SOB or diarrhea. Upon evaluation locally, he had a temperature of 99.5F and appeared lethargic. He also had anisocoria with left pupil 0.5mm bigger than the right. There was also question of left facial weakness. An MRI was obtained and revealed a large left hemispheric mass lesion with surrounding edema and mass effect. He was given 10mg of IV Decardron,100gm of IV Mannitol, intubated and hyperventilated and transferred to UIHC.,He was admitted to the Department of Medicine on 7/14/95, and transferred to the Department of Neurology on 7/17/95, after being extubated.,MEDS ON ADMISSION:, Bactrim DS qd, Diflucan 100mg qd, Acyclovir 400mg bid, Xanax, Stavudine 40mg bid, Rifabutin 300mg qd.,PMH:, 1) surgical correction of pyoloric stenosis, age 1, 2)appendectomy, 3) HIV/AIDS dx 1991. He was initially treated with AZT, then DDI. He developed chronic diarrhea and was switched to D4T in 1/95. However, he developed severe neuropathy and this was stopped 4/95. The diarrhea recured. He has Acyclovir resistant genital herpes and generalized psoriasis. He most recent CD4 count (within 1 month of admission) was 20.,FHX:, HTN and multiple malignancies of unknown type.,SHX:, Homosexual, in monogamous relationship with an HIV infected partner for the past 3 years.,EXAM: ,7/14/95 (by Internal Medicine): BP134/80, HR118, RR16 on vent, 38.2C, Intubated.,MS: Somnolent, but opened eyes to loud voices and would follow most commands.,CN: Pupils 2.5/3.0 and "equally reactive to light." Mild horizontal nystagmus on rightward gaze. EOM were otherwise intact.,MOTOR: Moved 4 extremities well.,Sensory/Coord/Gait/Station/Reflexes: not done.,Gen EXAM: Penil ulcerations.,EXAM:, 7/17/96 (by Neurology): BP144/73, HR59, RR20, 36.0, extubated.,MS: Alert and mildly lethargic. Oriented to name only. Thought he was a local hospital and that it was 1/17/1994. Did not understand he had a brain lesion.,CN: Pupils 6/5.5 decreasing to 4/4 on exposure to light. EOM were full and smooth. No RAPD or light-near dissociation. papilledema (OU). Right lower facial weakness and intact facial sensation to PP testing. Gag-shrug and corneal responses were intact, bilaterally. Tongue midline.,MOTOR: Grade 5- strength on the right side.,Sensory: no loss of sensation on PP/VIB/PROP testing.,Coord: reduced speed and accuracy on right FNF and right HKS movements.,Station: RUE pronator drift.,Gait: not done.,Reflexes: 2+/2 throughout. Babinski sign present on right and absent on left.,Gen Exam: unremarkable except for the genital lesion noted by Internal medicine.,COURSE:, The outside MRI was reviewed and was notable for the left frontal/parietal mass lesion with surround edema. The mass inhomogenously enhanced with gadolinium contrast.,The findings were consistent most with lymphoma, though toxoplasmosis could not be excluded. He refused brain biopsy and was started on empiric treatment for toxoplasmosis. This consisted of Pyrimethamine 75mg qd and Sulfadiazine 2 g bid. He later became DNR and was transferred at his and his partner's request Back to a local hospital.,He never returned for follow-up.
---
DESCRIPTION: MRI Brain: Probable CNS Lymphoma v/s toxoplasmosis in a patient with AIDS/HIV.

This situation involves a patient with AIDS who presents with neurological symptoms and a brain mass, which is possibly CNS lymphoma or toxoplasmosis. These conditions are severe and life-threatening, especially in a patient with a compromised immune system due to AIDS. Prompt and accurate diagnosis is crucial for appropriate management and treatment. The patient also has other complicating factors, such as a history of medication-resistant infections and severe neuropathy. The refusal of a brain biopsy and decision to start empiric treatment indicates high stakes in terms of life risk and treatment outcomes. Therefore, this situation requires urgent attention and expert medical care.