Medical Specialty: Surgery
Sample Name: Arthroscopic Rotator Cuff Repair - 1

PREOPERATIVE DIAGNOSIS: , Rotated cuff tear, right shoulder.,POSTOPERATIVE DIAGNOSES:,1.  Rotated cuff tear, right shoulder.,2.  Glenoid labrum tear.,PROCEDURE PERFORMED:,1.  Arthroscopy with arthroscopic glenoid labrum debridement.,2.  Subacromial decompression.,3.  Rotator cuff repair, right shoulder.,SPECIFICATIONS:,  Intraoperative procedure was done at Inpatient Operative Suite, room #1 at ABCD Hospital.  This was done under interscalene and subsequent general anesthetic in the modified beach chair position.,HISTORY AND GROSS FINDINGS: , The patient is a 48-year-old with male who has been suffering increasing right shoulder pain for a number of months prior to surgical intervention.  He was completely refractory to conservative outpatient therapy.  After discussing the alternative care as well as the advantages, disadvantages, risks, complications, and expectations, he elected to undergo the above stated procedure on this date.,Intraarticularly, the joint was observed.  There was noted to be a degenerative glenoid labrum tear.  The biceps complex was otherwise intact.  There were minimal degenerative changes at the glenohumeral joint.  Rotator cuff tear was appreciated on the inner surface.  Subacromially, the same was true.  This was an elliptical to V-type tear.  The patient has a grossly positive type III acromion.,OPERATIVE PROCEDURE: , The patient was laid supine on the operating table after receiving interscalene and then general anesthetic by the Anesthesia Department.  He was safely placed in modified beach chair position.  He was prepped and draped in the usual sterile manner.  Portals were created outside to end, posterior to anterior, and ultimately laterally in the typical fashion.  Upon complete diagnostic arthroscopy was carried out in the intraarticular aspect of the joint, a 4.2 meniscus shaver was placed anteriorly with the scope posteriorly.  Debridement was carried out to the glenoid labrum.  The biceps was probed and noted to be intact.  Undersurface of the rotator cuff was debrided with the shaver along with debridement of the subchondral region of the greater tuberosity attachment.,After this, instrumentation was removed.  The scope was placed subacromially and a lateral portal created.  Gross bursectomy was carried out in a stepwise fashion to the top part of the cuff as well as in the gutters.  An anterolateral portal was created.  Sutures were placed via express silk as well as other sutures with a #2 fiber wire.  With passing of the suture, they were tied with a slip-tight knot and then two half stitches.  There was excellent reduction of the tear.  Superolateral portal was then created.  A #1 Mitek suture anchor was then placed in the posterior cuff to bring this over to bleeding bone.  _______ suture was placed.  The implant was put into place.  The loop was grabbed and it was impacted in the previously drilled holes.  There was excellent reduction of the tear.,Trial range of motion was carried out and seemed to be satisfactory.,Prior to this, a subacromial decompression was accomplished after release of CA ligament with the vapor Bovie.  A 4.8 motorized barrel burr was utilized to sequentially take this down from the type III acromion to a flat type I acromion.,After all was done, copious irrigation was carried out throughout the joint.  Gross bursectomy lightly was carried out to remove all bony elements.  A pain buster catheter was placed through a separate portal and cut to length.  0.5% Marcaine was instilled after portals were closed with #4-0 nylon.  Adaptic, 4 x 4s, ABDs, and Elastoplast tape placed for dressing.  The patient was ultimately transferred to his cart and PACU in apparent satisfactory condition.  Expected surgical prognosis of this patient is fair.
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DESCRIPTION: Rotated cuff tear, right shoulder.  Glenoid labrum tear.  Arthroscopy with arthroscopic glenoid labrum debridement, subacromial decompression, and rotator cuff repair, right shoulder.

surgery, subacromial decompression, rotator cuff repair, arthroscopic glenoid labrum debridement, arthroscopy, glenoid labrum tear, glenoid labrum, cuff, tear, arthroscopic, subacromial, decompression, debridement, rotator, glenoid, labrum, shoulder,

Arthroscopic rotator cuff repair and associated procedures, while common, are still significant surgeries involving general anesthesia and potential complications. The stakes are heightened by the need for precision and post-operative recovery management. Considering potential risks and the significant discomfort and impact on functionality pre-surgery, this situation is moderately high-stakes. The prognosis and recovery depend on surgical precision and patient adherence to post-operative care.


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

Medical Specialty: Surgery
Sample Name: Bunionectomy & Akin Osteotomy

PREOPERATIVE DIAGNOSIS: , Bunion, left foot.,POSTOPERATIVE DIAGNOSIS: ,Bunion, left foot.,PROCEDURE PERFORMED:,1.  Bunionectomy with first metatarsal osteotomy base wedge type with internal screw fixation.,2.  Akin osteotomy with internal wire fixation of left foot.,HISTORY: , This 19-year-old Caucasian female presents to ABCD General Hospital with the above chief complaint.  The patient states she has had worsening bunion deformity for as long as she could not remember.  She does have a history of Charcot-Marie tooth disease and desires surgical treatment at this time.,PROCEDURE: , An IV was instituted by the Department of Anesthesia in the preoperative holding area.  The patient was transported to the operating room and placed on operating table in the supine position with a safety belt across her lap.  Copious amounts of Webril were placed on the left ankle followed by a blood pressure cuff.  After adequate sedation by the Department of Anesthesia, a total of 15 cc of 1:1 mixture of 1% lidocaine plain and 0.5% Marcaine plain were injected in a Mayo block type fashion surrounding the lower left first metatarsal.  The foot was then prepped and draped in the usual sterile orthopedic fashion.  The foot was elevated from the operating table and exsanguinated with an Esmarch bandage.  The pneumatic ankle tourniquet was inflated to 250 mmHg and the foot was lowered to the operating field.  The stockinette was reflected, the foot was cleansed with a wet and dry sponge.  Approximately 5 cm incision was made dorsomedially over the first metatarsal.,The incision was then deepened with #15 blade.  All vessels encountered were ligated for hemostasis.  Care was taken to preserve the extensor digitorum longus tendon.  The capsule over the first metatarsal phalangeal then was identified where a dorsal capsular incision was then created down to the level of bone.  Capsule and periosteum was reflected off the first metatarsal head.  At this time, the cartilage was inspected and noted to be white, shiny, and healthy cartilage.  There was noted to be a prominent medial eminence.  Attention was then directed to first interspace where a combination of blunt and sharp dissection was done to perform a standard lateral release.  The abductor tendon attachments were identified and transected.  The lateral capsulotomy was performed.  The extensor digitorum brevis tendon was identified and transected.  Attention was then directed to the prominent medial eminence, which was resected with a sagittal saw.  Intraoperative assessment of pes was performed and pes was noted to be normal.,At this time, a regional incision was carried more approximately about 1.5 cm.  The capsular incision was then extended and the proximal capsule and periosteum were reflected off the first metatarsal.  The first metatarsal cuneiform joint was identified.  A 0.45 K-wire was then inserted into the base of the first metatarsal approximately 1 cm from the first cuneiform joint perpendicular to the weightbearing surface.  This K-wire was used as an access guide for a Juvaro type oblique base wedge osteotomy.  The sagittal saw was then used to creat a closing base wedge osteotomy with the apex being proximal medial.  The osteotomy site was then feathered and tilted with tight estimation of the bony edges.  The cortical hinge was maintained.  A 0.27 x 24 mm screw was then inserted in a standard AO fashion.  At this time, there was noted to be tight compression of the osteotomy site.  A second 2.7 x 16 mm screw was then inserted more distally in the standard AO fashion with compression noted.  The ________ angle was noted to be significantly released.  Reciprocating rasp was then used to smoothen any remaining sharp edges.  The 0.45 k-wire was removed.  The foot was loaded and was noted to fill the remaining abduction of the hallux.  At this time, it was incised to perform an Akin osteotomy.,Original incision was then extended distally approximately 1 cm.  The incision was then deepened down to the level of capsule over the base of the proximal phalanx.  Again care was taken to preserve the extensor digitorum longus tendon.  The capsule was reflected off of the base of the proximal phalanx.  An Akin osteotomy was performed with the apex being lateral and the base being medial.  After where the bone was resected, it was feathered until tight compression was noted without tension at the osteotomy site.  Care was taken to preserve the lateral hinge.  At 1.5 wire passed and a drill was then used to create drill hole proximal and distally to the osteotomy site in order for passage of 28 gauge monofilament wire.  The #28 gauge monofilament wire was passed through the drill hole and tightened down until compression and tight ________ osteotomy site was noted.  The remaining edge of the wire was then buried in the medial most distal drill hole.  The area was then inspected and the foot was noted with significant reduction of the bunion deformity.  The area was then flushed with copious amounts of sterile saline.  Capsule was closed with #3-0 Vicryl followed by subcutaneous closure with #4-0 Vicryl in order to decrease tension of the incision site.  A running #5-0 subcuticular stitch was then performed.  Steri-Strips were applied.  Total of 1 cc dexamethasone phosphate was then injected into the surgical site.  Dressings consisted of Owen silk, 4x4s, Kling, Kerlix.  The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all five digits of the left foot.  Posterior splint was then placed on the patient in the operating room.,The patient tolerated the above procedure and anesthesia well without complications.  The patient was transferred back to the PACU with vital signs stable and vascular status intact to the left foot.  The patient was given postoperative instructions to be strictly nonweightbearing on the left foot.  The patient was given postop pain prescriptions for Vicodin and instructed to take one q.4-6h. p.r.n. for pain as well as Naprosyn 500 mg p.o. q. b.i.d.  The patient is to follow-up with Dr. X in his office in four to five days as directed.
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DESCRIPTION: Bunion, left foot.  Bunionectomy with first metatarsal osteotomy base wedge type with internal screw fixation and Akin osteotomy with internal wire fixation of left foot.

surgery, bunionectomy, akin osteotomy, internal wire fixation, internal screw fixation, osteotomy, metatarsal, metatarsal osteotomy, extensor digitorum, drill hole, osteotomy site, foot

The medical procedure described, a Bunionectomy with Akin Osteotomy, is a common surgical intervention for bunion correction. While surgery always carries some level of risk, this type of procedure is generally routine and not extremely high-risk. The patient is young and there are no mentioned intraoperative complications or significant comorbidities that would elevate the stakes considerably. Thus, the situation can be considered relatively low-stakes in the context of surgical procedures.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: General Medicine
Sample Name: Itchy Rash - ER Visit

CHIEF COMPLAINT:,  Itchy rash.,HISTORY OF PRESENT ILLNESS: , This 34-year-old gentleman awoke this morning noting some itchiness to his back and then within very a short period of time realized that he had an itchy rash all over his torso and arms.  No facial swelling.  No tongue or lip swelling.  No shortness of breath, wheezing, or other associated symptoms.  He cannot think of anything that could have triggered this off.  There have been no changes in his foods, medications, or other exposures as far as he knows.  He states a couple of days ago he did work and was removing some insulation but does not remember feeling itchy that day.,PAST MEDICAL HISTORY: , Negative for chronic medical problems.  No local physician.  Has had previous back surgery and appendectomy, otherwise generally healthy.,REVIEW OF SYSTEMS: , As mentioned denies any oropharyngeal swelling.  No lip or tongue swelling.  No wheezing or shortness of breath.  No headache.  No nausea.  Notes itchy rash, especially on his torso and upper arms.,SOCIAL HISTORY: , The patient is accompanied with his wife.,FAMILY HISTORY: , Negative.,MEDICATIONS: , None.,ALLERGIES: , TORADOL, MORPHINE, PENICILLIN, AND AMPICILLIN.,PHYSICAL EXAMINATION: , VITAL SIGNS:  The patient was afebrile.  He is slightly tachycardic, 105, but stable blood pressure and respiratory rate.  GENERAL:  The patient is in no distress.  Sitting quietly on the gurney.  HEENT:  Unremarkable.  His oral mucosa is moist and well hydrated.  Lips and tongue look normal.  Posterior pharynx is clear.  NECK:  Supple.  His trachea is midline.  There is no stridor.  LUNGS:  Very clear with good breath sounds in all fields.  There is no wheezing.  Good air movement in all lung fields.  CARDIAC:  Without murmur.  Slight tachycardia.  ABDOMEN:  Soft, nontender.  SKIN:  Notable for a confluence erythematous, blanching rash on the torso as well as more of a blotchy papular, macular rash on the upper arms.  He noted some on his buttocks as well.  Remaining of the exam is unremarkable.,ED COURSE: , The patient was treated with epinephrine 1:1000, 0.3 mL subcutaneously along with 50 mg of Benadryl intramuscularly.  After about 15-20 minutes he states that itching started to feel better.  The rash has started to fade a little bit and feeling a lot more comfortable.,IMPRESSION:,  ACUTE ALLERGIC REACTION WITH URTICARIA AND PRURITUS.,ASSESSMENT AND PLAN: , The patient has what looks to be some type of allergic reaction, although the underlying cause is difficult to assess.  He will make sure he goes home to look around to see if there is in fact anything that changed recently that could have triggered this off.  In the meantime, I think he can be managed with some antihistamine over-the-counter.  He is responding already to Benadryl and the epinephrine that we gave him here.  He is told that if he develops any respiratory complaints, shortness of breath, wheezing, or tongue or lip swelling he will return immediately for evaluation.  He is discharged in stable condition.
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DESCRIPTION: This 34-year-old gentleman awoke this morning noting some itchiness to his back and then within very a short period of time realized that he had an itchy rash all over his torso and arms.

general medicine, urticaria, pruritus, lip swelling, allergic reaction, itchy rash, torso, swelling, itchy, rash,

The situation involves an acute allergic reaction with urticaria and pruritus for which the patient visited an emergency room. While this presents some level of immediate concern, the patient's condition quickly improved with treatment (epinephrine and Benadryl), and he was stable when discharged. There were no severe symptoms like respiratory distress or anaphylaxis at the time of examination and treatment. Thus, while prompt medical assessment was necessary, the situation was managed effectively in the ER, suggesting moderate stakes rather than high stakes.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Radical Mastectomy - 1

PROCEDURE PERFORMED: , Modified radical mastectomy.,ANESTHESIA: , General endotracheal tube.,PROCEDURE:  ,After informed consent was obtained, the patient was brought to the operative suite and placed supine on the operating room table.  General endotracheal anesthesia was induced without incident.  The patient was prepped and draped in the usual sterile manner.  Care was taken to ensure that the arm was placed in a relaxed manner away from the body to facilitate exposure and to avoid nerve injury.,An elliptical incision was made to incorporate the nipple-areolar complex and the previous biopsy site.  The skin incision was carried down to the subcutaneous fat but no further.  Using traction and counter-traction, the upper flap was dissected from the chest wall medially to the sternal border, superiorly to the clavicle, laterally to the anterior border of the latissimus dorsi muscle, and superolaterally to the insertion of the pectoralis major muscle.  The lower flap was dissected in a similar manner down to the insertion of the pectoralis fascia overlying the fifth rib medially and laterally out to the latissimus dorsi.  Bovie electrocautery was used for the majority of the dissection and hemostasis tying only the large vessels with 2-0 Vicryl.  The breast was dissected from the pectoralis muscle beginning medially and progressing laterally removing the pectoralis fascia entirely.  Once the lateral border of the pectoralis major muscle was identified, the pectoralis muscle was retracted medially and the interpectoral fat was removed with the specimen.,The axillary dissection was then begun by incising the fascia overlying axilla proper allowing visualization of the axillary vein.  The highest point of axillary dissection was then marked with a long stitch for identification by the surgical pathologist.  The axilla was then cleared of its contents by sharp dissection.  Small vessels entering the axillary vein were clipped and divided.  The axilla was cleared down to the chest wall, and dissection was continued laterally to the subscapular vein.  The long thoracic nerve was cleared identified lying against the chest and was carefully preserved.  The long thoracic nerve represented the posterior most aspect of the dissection.  As the axillary contents were dissected in the posterolateral axilla, the thoracodorsal nerve was identified and carefully preserved.  The dissection continued caudally until the entire specimen was freed and delivered from the operative field.  Copious water lavage was used to remove any debris, and hemostasis was obtained with Bovie electrocautery.,Two Jackson-Pratt drains were inserted through separate stab incisions below the initial incision and cut to fit.  The most posterior of the 2 was directed into the axilla and the other directed anteriorly across the pectoralis major.  These were secured to the skin using 2-0 silk, which was Roman-sandaled around the drain.,The skin incision was approximated with skin staples.  A dressing was applied.  The drains were placed on "grenade" suction.  All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently extubated and taken to the recovery room in good and stable condition.
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DESCRIPTION: Modified radical mastectomy.  An elliptical incision was made to incorporate the nipple-areolar complex and the previous biopsy site.  The skin incision was carried down to the subcutaneous fat but no further.

obstetrics / gynecology, latissimus dorsi muscle, pectoralis major muscle, pectoralis fascia, axillary vein, thoracic nerve, radical mastectomy, pectoralis major, axillary, incision, mastectomy, fascia, muscle, pectoralis,

The scenario describes a surgical procedure, specifically a modified radical mastectomy, which involves the removal of breast tissue and dissection of the axillary region to remove lymph nodes. Such procedures are inherently high-stakes due to the potential for complications, the need for precision to preserve important nerves, and the implications for the patient's cancer treatment and recovery outcomes. However, the description notes that there were no incidents during anesthesia induction, and the patient tolerated the procedure well, and was stable post-surgery. Despite this positive outcome, surgical procedures like this are high-stakes due to their complexity and the critical nature of the outcome on the patient's health.


Medical Specialty: Podiatry
Sample Name: Foot Infection Management

REASON FOR CONSULTATION:  ,Management for infection of the left foot.,HISTORY: , The patient is a 26-year-old short Caucasian male who appears in excellent health, presented a week ago as he felt some pain in the ball of his left foot.  He noticed a small dark spot.  He did not remember having had any injuries to that area specifically no puncture wounds.  He had not been doing any outdoor works or activities.  No history of working outdoors, has not been to the beach or to the lake, has not been out of town.  His swelling progressed so he went to see Dr. X 4 days ago.  The area was debrided in the office and he was placed on Keflex.  It was felt that may be he had a foreign body, but nothing was found in the office and x-ray was negative for opaque foreign bodies.  His foot got worse with more swelling and at this time purulent, too red and was admitted to the hospital today, is scheduled for surgical exploration this evening.  Ancef and Cipro were prescribed today.  He denies any fever, chills, red streaks, lymphadenitis.  He had a tetanus shot in 2002 most recently.  He had childhood asthma.  He uses alcohol socially.  He works full time.  He is an electrician.,ALLERGIES:,  ACCUTANE.,PHYSICAL EXAMINATION,GENERAL:  Well-developed, well-nourished adult Caucasian male in no acute distress.,VITAL SIGNS:  His weight is 190 pounds, height 69 inches, temperature 98, respirations 20, pulse 78, and blood pressure 143/63, O2 sat 98% on room air.,HEENT:  Mouth unremarkable.,NECK:  Supple.,LUNGS:  Clear.,HEART:  Regular rate rhythm.  No murmur or gallop.,ABDOMEN:  Soft and nontender.,EXTREMITIES:  Left foot on the plantar side by the head of the first metatarsal has an open wound of about 10 mm in diameter with thick reddish purulent discharge and surrounding edema.  There is bloodied blister around it.  The area is tender to touch, warm with a slight edema of the rest of the foot with very faint erythema.  There is some mild intertrigo between the fourth and fifth left toes.  Palpable pedal pulses.  Leg unremarkable.  No femoral or inguinal lymphadenopathy.,LABORATORY: , Labs show white cell count of 6300, hemoglobin 13.6, platelet count of _____ with 80 monos, 17 eos _____, creatinine 1.3, BUN of 16, glucose 110.  Calcium, ferritin, albumin, bilirubin, ALT, AST, alkaline phosphatase are normal.  PT and PTT normal and the sed rate was 35 mm per hour.,IMPRESSION:  ,Abscess of the left foot, etiology unclear at this time.  Possibility of foreign body.,RECOMMENDATIONS/PLAN: , He is going to be discharged in about half-an-hour.  Cultures, Gram stain, fungal cultures, and smear to be obtained.  I have changed his antibiotic to vancomycin plus Maxipime.  He is currently on tetanus immunizations so no need for booster at this time.,
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DESCRIPTION: Abscess of the left foot, etiology unclear at this time.  Possibility of foreign body.

podiatry, accutane, possibility of foreign body, foot etiology, foreign body, infection, foot, abscess,

The case involves a potentially serious foot infection that has not responded to initial treatments, necessitating hospital admission and surgical exploration. This suggests the situation has escalated beyond a simple infection. The potential for complications, such as the spread of the infection or the involvement of a foreign body, which could lead to more severe outcomes, increases the stakes. The patient's general health is good, which may mitigate some risk, but the escalation to surgical intervention highlights the seriousness.


Medical Specialty: Orthopedic
Sample Name: Discharge Summary - Hip Surgery

ADMITTING DIAGNOSIS:,  Posttraumatic AV in right femoral head.,DISCHARGE DIAGNOSIS:,  Posttraumatic AV in right femoral head.,SECONDARY DIAGNOSES PRIOR TO HOSPITALIZATION:,1.  Opioid use.,2.  Right hip surgery.,3.  Appendectomy.,4.  Gastroesophageal reflux disease.,5.  Hepatitis diagnosed by liver biopsy.,6.  Blood transfusion.,6.  Smoker.,7.  Trauma with multiple orthopedic procedures.,8.  Hip arthroscopy.,POSTOP COMORBIDITIES: , Postop acute blood loss anemia requiring transfusion and postop pain.,PROCEDURES DURING THIS HOSPITALIZATION:,  Right total hip arthroplasty and removal of hardware.,CONSULTS:,  Acute pain team consult.,DISPOSITION: , Home.,HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE:,  For details, please refer to clinic notes and OP notes.  In brief, the patient is a 47-year-old female with a posttraumatic AV in the right femoral head.  She came in consult with Dr. X who after reviewing the clinical and radiological findings recommended she undergo a right total hip arthroplasty and removal of old hardware.  After being explained the risks, benefits, alternative options, and possible outcomes of surgery, she was agreeable and consented to proceed and therefore on the day of her admission, she was sent to the operating room where she underwent a right total hip arthroplasty and removal of hardware without any complications.  She was then transferred to PACU for recovery and postop orthopedic floor for convalescence, physical therapy, and discharge planning.  DVT prophylaxis was initiated with Lovenox.  Postop pain was adequately managed with the aid of Acute Pain team.  Postop acute blood loss anemia was treated with blood transfusions to an adequate level of hemoglobin.  Physical therapy and occupational therapy were initiated and continued to work with her towards discharge clearance on the day of her discharge.,DISPOSITION:,  Home.  On the day of her discharge, she was afebrile, vital signs were stable.  She was in no acute distress.  Her right hip incision was clean, dry, and intact.  Extremity was warm and well perfused.  Compartments were soft.  Capillary refill less than two seconds.  Distal pulses were present.,PREDISCHARGE LABORATORY FINDINGS: , White count of 10.9, hemoglobin of 9.5, and BMP is pending.,DISCHARGE INSTRUCTIONS: , Continue diet as before.,ACTIVITY: , Weightbearing as tolerated in the right lower extremity as instructed.  Do not lift, drive, move furniture, do strenuous activity for six weeks.  Call Dr. X if there is increased temperature greater than 101.5, increased redness, swelling, drainage, increased pain that is not relieved by current pain regimen as per postop orthopedic discharge instruction sheet.,FOLLOW-UP APPOINTMENT:  Follow up with Dr. X in two weeks.
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DESCRIPTION: A 47-year-old female with a posttraumatic AV in the right femoral head.

The situation involves the discharge summary for a patient who underwent a significant orthopedic procedure: a right total hip arthroplasty. While this is a major surgery requiring careful follow-up and management (including monitoring for complications like infection or DVT), the patient has been discharged in stable condition. The presence of comorbidities and the complex nature of the surgery elevate the stakes slightly, but there are no immediate life-threatening conditions presented in the summary. The discharge instructions and follow-up arrangements suggest a structured post-operative care plan, which helps manage the risk. Therefore, while there are important health considerations, this situation is not extremely high-stakes.


Medical Specialty: Surgery
Sample Name: Central Venous & Arterial  Line

INDICATIONS FOR PROCEDURES: , Impending open-heart surgery for atrial septectomy and bilateral bidirectional Glenn procedure.,The patient was already under general anesthesia in the operating room.  Antibiotic prophylaxis with cephazolin and gentamicin were already given.  A strict aseptic technique was used including use of gowns, mask, and gloves, etc.  The skin was cleansed with alcohol and then prepped with ChloraPrep solution.,PROCEDURE #1:,  Insertion of central venous line.,DESCRIPTION OF PROCEDURE #1: , Attention was directed to the right groin.  A Cook 4-French double-lumen 12-cm long central venous heparin-coated catheter kit was opened.  Using the 21-gauge needle that comes with this kit, the needle was inserted approximately 2 cm below the right inguinal ligament just medial to the pulsations of the femoral artery.  There was good venous blood return on the first try.  Using the Seldinger technique, the soft J-end of the wire was inserted through the needle without resistance approximately 15 cm.  It was then exchanged for a 5-French dilator followed by the 4-French double-lumen catheter and the wire was removed intact.  There was good blood return from both lumens, which were flushed with heparinized saline.  The catheter was sutured to the skin at three points with #4-0 silk for stabilization.,PROCEDURE #2:,  Insertion of arterial line.,DESCRIPTION OF PROCEDURE #2:,  Attention was directed to the left wrist, which was placed on wrist rest.  The Allen test was normal.  A Cook 2.5-French 5 cm long arterial catheter kit was opened.  A 22-gauge IV cannula was used to enter the artery, which was done on the first try with good pulsatile blood return.  Using the Seldinger technique, the catheter was exchanged for a 2.5-French catheter and the wire was removed intact.  There was pulsatile blood return and the catheter was flushed with heparinized saline solution.  It was sutured to the skin with #4-0 silk at three points for stabilization.,Both catheters functioned well throughout the procedure.  The distal circulation of the leg and the hand was intact immediately after insertion, approximately 20 minutes later, and at the end of the procedure.  There were no complications.,PROCEDURE #3: , Insertion of transesophageal echocardiography probe.,DESCRIPTION OF PROCEDURE #3: , The probe was inserted under direct vision because initially there was some resistance to insertion.  Under direct vision, using the #2 Miller blade, the upper esophageal opening was visualized and the probe was passed easily without resistance.  There was good visualization of the heart.  The probe was used by the pediatric cardiologist for preoperative and postoperative diagnostic echocardiography.  The probe was removed at the end.  There was no trauma and there was no blood tingeing.,
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DESCRIPTION: Insertion of central venous line and arterial line and transesophageal echocardiography probe.

surgery, open-heart surgery, central venous line, arterial line, transesophageal echocardiography probe, glenn procedure, atrial septectomy, aseptic technique, pulsatile blood, central venous, blood return, arterial, central, probe, insertion, catheter

The described scenario involves preparing a patient for a complex surgical procedure, specifically open-heart surgery. The procedures mentioned, including the insertion of central venous and arterial lines and a transesophageal echocardiography probe, are critical components in monitoring and supporting the patient during and after such an operation. These procedures are essential to ensure the patient remains stable and to manage potential surgical complications. Therefore, they are inherently high-stakes due to the serious nature of the surgery and the need for precision and caution to prevent complications.


Medical Specialty: Consult - History and Phy.
Sample Name: Neurologic Consultation

REASON FOR CONSULTATION: , Neurologic consultation was requested by Dr. X to evaluate her seizure medication and lethargy.,HISTORY OF PRESENT ILLNESS: , The patient is well known to me.  She has symptomatic partial epilepsy secondary to a static encephalopathy, cerebral palsy, and shunted hydrocephalus related to prematurity.  She also has a history of factor V Leiden deficiency.  She was last seen at neurology clinic on 11/16/2007.  At that time, instructions were given to mom to maximize her Trileptal dose if seizures continue.  She did well on 2 mL twice a day without any sedation.  This past Friday, she had a 25-minute seizure reportedly.  This consisted of eye deviation, unresponsiveness, and posturing.  Diastat was used and which mom perceived was effective.  Her Trileptal dose was increased to 3 mL b.i.d. yesterday.,According to mom since her shunt revision on 12/18/2007, she has been sleepier than normal.  She appeared to be stable until this past Monday about six days ago, she became more lethargic and had episodes of vomiting and low-grade fevers.  According to mom, she had stopped vomiting since her hospitalization.  Reportedly, she was given a medication in the emergency room.  She still is lethargic, will not wake up spontaneously.  When she does awaken however, she is appropriate, and interacts with them.  She is able to eat well; however her overall p.o. intake has been diminished.  She has also been less feisty as her usual sounds.  She has been seizure free since her admission.,LABORATORY DATA: , Pertinent labs obtained here showed the following:  CRP is less than 0.3, CMP normal, and CBC within normal limits.  CSF cultures so far is negative.  Dr. Limon's note refers to a CSF, white blood cell count of 2, 1 RBC, glucose of 55, and protein of 64.  There are no imaging studies in the computer.  I believe that this may have been done at Kaweah Delta Hospital and reviewed by Dr. X, who indicated that there was no evidence of shunt malfunction or infection.,CURRENT MEDICATIONS: , Trileptal 180 mg b.i.d., lorazepam 1 mg p.r.n., acetaminophen, and azithromycin.,PHYSICAL EXAMINATION:,GENERAL:  The patient was asleep, but easily aroused.  There was a brief period of drowsiness, which she had some jerky limb movements, but not seizures.  She eventually started crying and became agitated.  She made attempts to sit by bending her neck forward.  Fully awake, she sucks her bottle eagerly.,HEENT:  She was obviously visually impaired.  Pupils were 3 mm, sluggishly reactive to light.,EXTREMITIES:  Bilateral lower extremity spasticity was noted.  There was increased flexor tone in the right upper extremity.  IV was noted on the left hand.,ASSESSMENT:  ,Seizure breakthrough due to intercurrent febrile illness.  Her lethargy could be secondary to a viral illness with some component of medication effect since her Trileptal dose was increased yesterday and these are probable explanations if indeed shunt malfunction has been excluded.,I concur with Dr. X's recommendations.  I do not recommend any changes in Trileptal for now.  I will be available while she remains hospitalized.,
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DESCRIPTION: Neurologic consultation was requested to evaluate her seizure medication and lethargy.

consult - history and phy., lethargy, encephalopathy, cerebral palsy, shunted hydrocephalus, seizure breakthrough, shunt malfunction, neurologic consultation, neurologic, seizure, trileptal

The situation described is a medical consultation for a patient with a history of epilepsy, cerebral palsy, and shunted hydrocephalus. The stakes are fairly high as it involves assessing the appropriateness of seizure medication amidst symptoms that could be due to complications like shunt malfunction or infection. Proper management is crucial to prevent potential life-threatening issues such as increased intracranial pressure if the shunt is malfunctioning or inappropriate seizure control worsening the patient's condition.


Medical Specialty: Discharge Summary
Sample Name: Knee Surgery - Discharge Summary

CHIEF COMPLAINT:,  Decreased ability to perform daily living activities secondary to right knee surgery.,HISTORY OF PRESENT ILLNESS: , The patient is a 61-year-old white female status post right total knee replacement secondary to degenerative joint disease performed by Dr. A at ABCD Hospital on 08/21/2007.  The patient was transfused with 2 units of autologous blood postoperatively.  She received DVT prophylaxis with a combination of Coumadin, Lovenox, SCD boots, and TED stockings.  The remainder of her postoperative course was uneventful.  She was discharged on 08/24/2007 from ABCD Hospital and admitted to the transitional care unit at XYZ Services for evaluation and rehabilitation.  The patient reports that her last bowel movement was on 08/24/2007 just prior to her discharge from ABCD Hospital.  She denies any urological symptoms such as dysuria, incomplete bladder emptying or other voiding difficulties.  She reports having some right knee pain, which is most intense at a "certain position."  The patient is unable to elaborate on which "certain position" causes her the most discomfort.,ALLERGIES:,  NKDA.,PAST MEDICAL HISTORY: , Hypertension, hypothyroidism, degenerative joint disease, GERD, anxiety disorder, Morton neuroma of her feet bilaterally, and distant history of migraine headaches some 30 years ago.,MEDICATIONS:,  On transfer, Celebrex, Coumadin, Colace, Synthroid, Lovenox, Percocet, Toprol XL, niacin, and trazodone.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature 96.5, blood pressure 127/72, pulse 70, respiratory rate 20, 95% O2 saturation on room air.,GENERAL:  No acute distress at the time of the exam except as mentioned above complains of right knee pain at "certain position.",HEENT:  Normocephalic.  Sclerae nonicteric.  EOMI.  Dentition in good repair.  Tongue is in midline with no evidence of thrush.,NECK:  No thyroid enlargement.  Trachea is midline.,LUNGS:  Clear to auscultation.,HEART:  Regular rate and rhythm.  Normal S1 and S2.,ABDOMEN:  Soft, nontender, and nondistended.  No organomegaly.,EXTREMITIES:  The right knee incision is intact.  Steri-Strips are in place.  There is some diffuse right knee edema and some limited ecchymosis as well.  No calf tenderness bilaterally.  Pedal pulses are palpable bilaterally.,MENTAL STATUS:  The patient appears slightly anxious during the interview and exam, but she was alert and oriented.,HOSPITAL COURSE: , As mentioned above, the patient was admitted on 08/24/2007 to the Transitional Care Unit at XYZ Services for evaluation and rehabilitation.  She was seen in consultation by Physical Therapy and Occupational Therapy and had begun her rehabilitation till recovery.  The patient had been properly instructed regarding using the CPM machine and she had been instructed as well to limit each CPM session to two hours.  Very early in her hospitalization, the patient enthusiastically used the CPM much longer than two hours and consequently had increased right knee pain.  She remarked that she had a better degree of flexibility, but she did report an increased need for pain management.  Additionally, she required Ativan and at one point scheduled the doses of Ativan to treat her known history of anxiety disorder.  On the fourth hospital day, she was noted to have some rashes about the right upper extremity and right side of her abdomen.  The patient reported that this rash was itchy.  She reports that she had been doing quite a bit of gardening just prior to surgery and this was most likely contact dermatitis, most likely due to her gardening activities preoperatively.  She was treated with betamethasone cream applied to the rash b.i.d.  The patient's therapy had progressed and she continued to make a good progress.  At one point, the patient reported some insomnia due to right knee pain.  She was switched from Percocet to oxycodone SR 20 mg b.i.d. and she had good pain control with this using the Percocet only for breakthrough pain.  The DVT prophylaxis was maintained with Lovenox 40 mg subcu daily until the INR was greater than 1.7 and it was discontinued on 08/30/2007 when the INR was 1.92 within therapeutic range.  The Coumadin was adjusted accordingly according to the INRs during her hospital course.  Early in the hospital course, the patient had reported right calf tenderness and a venous Doppler study obtained on 08/27/2007 showed no DVT bilaterally.  Initial laboratory data includes a UA on 08/28/2007, which was negative.  Additionally, CBC showed a white count of 6.3, hemoglobin was 12.1, hematocrit was 35.3, and platelets were 278,000.  Chemistries were within normal limits.  Creatinine was 0.8, BUN was 8, anion gap was slightly decreased at 5, fasting glucose was 102.  The remainder of chemistries was unremarkable.  The patient continued to make great progress with her therapies so much so that we are anticipating her discharge on Monday, 09/03/2007.,DISCHARGE DIAGNOSES:,1.  Status post right total knee replacement secondary to degenerative joint disease performed on 08/21/2007.,2.  Anxiety disorder.,3.  Insomnia secondary to pain and anxiety postoperatively.,4.  Postoperative constipation.,5.  Contact dermatitis secondary to preoperative gardening activities.,6.  Hypertension.,7.  Hypothyroidism.,8.  Gastroesophageal reflux disease.,9.  Morton neuroma of the feet bilaterally.,10.  Distant history of migraine headaches.,INSTRUCTIONS GIVEN TO THE PATIENT AT THE TIME OF DISCHARGE: , The patient is advised to continue taking the following medications:  Celebrex 200 mg daily, for one month, Colace 100 mg b.i.d. for one month, Protonix 40 mg b.i.d. for one month, Synthroid 137 mcg daily, Diprosone cream 0.05% cream b.i.d. to the right arm and right abdomen, oxycodone SR 20 mg p.o. q.12h. for five days, then decrease to oxycodone SR 10 mg p.o. q.12h. for five days, Percocet 5/325 mg one to two tablets q.6h. to be used p.r.n. for breakthrough pain, trazodone 50 mg p.o. at bedtime p.r.n. for two weeks, Ativan 0.25 mg b.i.d. for two weeks, and Toprol-XL 50 mg daily.  The patient will also take Coumadin and the dose will be adjusted according to the INRs, which will be obtained every Monday and Thursday with results being sent to Dr. A and his fax number is 831-5926.  At the present time, the patient is taking Coumadin 7 mg daily.  She will remain on Coumadin for 30 days.  An INR is to be obtained on 09/03/2007 and should the Coumadin dose be changed, an addendum will be dictated to accompany this discharge summary.  Finally, the patient has a followup appointment with Dr. A on 09/21/2007 at noon at his office.  The patient is encouraged to follow up with her primary care physician, Dr. B.  As mentioned above, the patient will be discharged on 09/03/2007 in stable and improved condition since she is status post right total knee replacement and has made good progress with her therapies and rehabilitation.
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DESCRIPTION: Decreased ability to perform daily living activities secondary to right knee surgery.

The discharge summary outlined above relates to a patient who underwent knee surgery and involves managing postoperative recovery and various related health conditions. While the situation involves medical complexity, it is routine for postoperative care. Given that the patient is in stable and improved condition and there are follow-up and management plans in place, it is not an extremely high-stakes scenario. However, due diligence in following postoperative care instructions, particularly concerning anticoagulation therapy with Coumadin, is essential to prevent complications such as DVT, making this moderately important.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Single Frontal View of Chest

EXAM: , Single frontal view of the chest.,HISTORY: , Atelectasis.  Patient is status-post surgical correction for ASD.,TECHNIQUE: , A single frontal view of the chest was evaluated and correlated with the prior film dated mm/dd/yy.,FINDINGS:,  Current film reveals there is a right-sided central venous catheter, the distal tip appears to be in the superior vena cava.  Endotracheal tube with the distal tip appears to be in appropriate position, approximately 2 cm superior to the carina.  Sternotomy wires are noted.  They appear in appropriate placement.  There are no focal areas of consolidation to suggest pneumonia.  Once again seen is minimal amount of bilateral basilar atelectasis.  The cardiomediastinal silhouette appears to be within normal limits at this time.  No evidence of any pneumothoraces or pleural effusions.,IMPRESSION:,1.  There has been interval placement of a right-sided central venous catheter, endotracheal tube, and sternotomy wires secondary to patient's most recent surgical intervention.,2.  Minimal bilateral basilar atelectasis with no significant interval changes from the patient's most recent prior.,3.  Interval decrease in the patient's heart size which may be secondary to the surgery versus positional and technique.
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DESCRIPTION: Chest, Single view post OP for ASD (Atrial Septal Defect).

cardiovascular / pulmonary, atrial septal defect, central venous catheter, bilateral basilar atelectasis, single frontal view, distal tip, endotracheal tube, sternotomy wires, basilar atelectasis, atrial, venous, catheter, endotracheal, tube, sternotomy, atelectasis, chest, asd

The situation involves a post-operative assessment of a patient who recently underwent surgical correction for an Atrial Septal Defect (ASD). The imaging findings are being analyzed for the position and condition of various medical apparatus and the patient's current condition. While post-operative chest examinations are routine, they are crucial to ensure that medical devices are properly placed and there are no complications such as pneumothoraces or consolidations. However, the findings seem stable with no immediate life-threatening concerns noted, reducing the high-stakes nature of this specific report.


Medical Specialty: Orthopedic
Sample Name: TLIF

PREOPERATIVE DIAGNOSIS (ES):, L4-L5 and L5-S1 degenerative disk disease/disk protrusions/spondylosis with radiculopathy.,POSTOPERATIVE DIAGNOSIS (ES):, L4-L5 and L5-S1 degenerative disk disease/disk protrusions/spondylosis with radiculopathy.,PROCEDURE:,1. Left L4-L5 and L5-S1 Transforaminal Lumbar Interbody Fusion (TLIF).,2. L4 to S1 fixation (Danek M8 system).,3. Right posterolateral L4 to S1 fusion.,4. Placement of intervertebral prosthetic device (Danek Capstone spacers L4-L5 and L5-S1).,5. Vertebral autograft plus bone morphogenetic protein (BMP).,COMPLICATIONS:, None.,ANESTHESIA:, General endotracheal.,SPECIMENS:, Portions of excised L4-L5 and L5-S1 disks.,ESTIMATED BLOOD LOSS:, 300 mL.,FLUIDS GIVEN:, IV crystalloid.,OPERATIVE INDICATIONS:, The patient is a 37-year-old male presenting with a history of chronic, persistent low back pain as well as left lower extremity of radicular character were recalcitrant to conservative management. Preoperative imaging studies revealed the above-noted abnormalities. After a detailed review of management considerations with the patient and his wife, he was elected to proceed as noted above.,Operative indications, methods, potential benefits, risks and alternatives were reviewed. The patient and his wife expressed understanding and consented to proceed as above.,OPERATIVE FINDINGS:, L4-L5 and L5-S1 disk protrusion with configuration as anticipated from preoperative imaging studies. Pedicle screw placement appeared satisfactory with satisfactory purchase and positioning noted at all sites as well as satisfactory findings upon probing of the pedicular tracts at each site. In addition, all pedicle screws were stimulated with findings of above threshold noted at all sites. Spacer snugness and positioning appeared satisfactory. Electrophysiological monitoring was carried out throughout the procedure and remained stable with no undue changes reported.,DESCRIPTION OF THE OPERATION:, After obtaining proper patient identification and appropriate preoperative informed consent, the patient was taken to the operating room on a hospital stretcher in the supine position. After the induction of satisfactory general endotracheal anesthesia and placement of appropriate monitoring equipment by Anesthesiology as well as placement of electrophysiological monitoring equipment by the Neurology team, the patient was carefully turned to the prone position and placed upon the padded Jackson table with appropriate additional padding placed as needed. The patient's posterior lumbosacral region was thoroughly cleansed and shaved. The patient was then scrubbed, prepped and draped in the usual manner. After local infiltration with 1% lidocaine with 1: 200,000 epinephrine solution, a posterior midline skin incision was made extending from approximately L3 to the inferior aspect of the sacrum. Dissection was continued in the midline to the level of the posterior fascia. Self-retaining retractors were placed and subsequently readjusted as needed. The fascia was opened in the midline, and the standard subperiosteal dissection was then carried out to expose the posterior and posterolateral elements from L3-L4 to the sacrum bilaterally with lateral exposure carried out to the lateral aspect of the transverse processes of L4 and L5 as well as the sacral alae bilaterally. _____ by completing the exposure, pedicle screw fixation was carried out in the following manner. Screws were placed in systematic caudal in a cranial fashion. The pedicle screw entry sites were chosen using standard dorsal landmarks and fluoroscopic guidance as needed. Cortical openings were created at these sites using a small burr. The pedicular tracts were then preliminarily prepared using a Lenke pedicle finder. They were then probed and subsequently tapped employing fluoroscopic guidance as needed. Each site was "under tapped" and reprobed with satisfactory findings noted as above. Screws in the following dimensions were placed. 6.5-mm diameter screws were placed at all sites. At S1, 40-mm length screws were placed bilaterally. At L5, 40-mm length screws were placed bilaterally, and at L4, 40-mm length screws were placed bilaterally with findings as noted above. The rod was then contoured to span from the L4 to the S1 screws on the right. The distraction was placed across the L4-L5 interspace, and the connections were temporarily secured. Using a matchstick burr, a trough was then carefully created slightly off the midline of the left lamina extending from its caudal aspect to its more cranial aspect at the foraminal level. This was longitudinally oriented. A transverse trough was similarly carefully created from the cranial point of the longitudinal trough out to the lateral aspect of the pars against the foraminal level that is slightly caudal to the L4 pedicle. This trough was completed to the level of the ligamentum flavum using small angled curettes and Kerrison rongeurs, and this portion of the lamina along with the inferior L4 articular process was then removed as a unit using rongeurs and curettes. The cranial aspect of the left L5 superior articular process was then removed using a small burr and angled curettes and Kerrison rongeurs. A superior laminotomy was performed from the left L5 lamina and flavectomy was then carried out across this region of decompression, working from caudally to cranially and medially to laterally, again using curettes and Kerrison rongeurs under direct visualization. In this manner, the left lateral aspect of the thecal sac passing left L5 spinal nerve and exiting left L4 spinal nerve along with posterolateral aspect of disk space was exposed. Local epidural veins were coagulated with bipolar and divided. Gelfoam was then placed in this area. This process was then repeated in similar fashion; thereby, exposing the posterolateral aspect of the left L5-S1 disk space. As noted, distraction had previously been placed at L4-L5, this was released. Distraction was placed across the L5-S1 interspace. After completing satisfactory exposure as noted, a annulotomy was made in the posterolateral left aspect of the L5-S1 disk space. Intermittent neural retraction was employed with due caution afforded to the neural elements throughout the procedure. The disk space was entered, and diskectomy was carried out in routine fashion using pituitary rongeurs followed by the incremental sized disk space shavers as well as straight and then angled TLIF curettes to prepare the front plate. Herniated portions of the disk were also removed in routine fashion. The diskectomy and endplate preparation were carried out working progressively from the left towards the right aspect of the disk across the midline in routine fashion. After completing this disk space preparation, Gelfoam was again placed. The decompression was assessed and appeared to be satisfactory. The distraction was released, and attention was redirected at L4-L5, where again, distraction was placed and diskectomy and endplate preparation was carried out at this interspace again in similar fashion. After completing the disk space preparation, attention was redirected to L5-S1. Distraction was released at L4-L5 and again, reapplied at L5-S1, incrementally increasing size. Trial spaces were used, and a 10-mm height by 26-mm length spacer was chosen. A medium BMP kit was appropriately reconstituted. A BMP sponge containing morcellated vertebral autograft was then placed into the anterior aspect of the disk space. The spacer was then carefully impacted into position. The distraction was released. The spacer was checked with satisfactory snugness and positioning noted. This process was then repeated in similar fashion at L4-L5, again with placement of a 10-mm height by 26-mm length Capstone spacer, again containing BMP and again with initial placement of a BMP sponge with vertebral autograft anteriorly within the interspace. This spacer was also checked again with satisfactory snugness and positioning noted. The prior placement of the spacers and BMP, the wound was thoroughly irrigated and dried with satisfactory hemostasis noted. Surgicel was placed over the exposed dura and disk space. The distraction was released on the right and compression plates across the L5-S1 and L4-L5 interspaces and the connections fully tightened in routine fashion. The posterolateral elements on the right from L4 to S1 were prepared for fusion in routine fashion, and BMP sponges with supplemental vertebral autograft was placed in the posterolateral fusion bed as well as the vertebral autograft in the dorsal aspect of the L4-L5 and L5-S1 facets on the right in a routine fashion. A left-sided rod was appropriated contoured and placed to span between the L4 to S1 screws. Again compression was placed across the L4-L5 and L5-S1 segments, and these connections were fully secured. Thorough hemostasis was ascertained after checking the construct closely and fluoroscopically. The wound was closed using multiple simple interrupted 0-Vicryl sutures to reapproximate the deep paraspinal musculature in the midline. The superficial paraspinal musculature in posterior fashion was closed in the midline using multiple simple interrupted 0-Vicryl sutures. The suprafascial subcutaneous layers were closed using multiple simple interrupted #0 and 2-0 Vicryl sutures. The skin was then closed using staples. Sterile dressings were then applied and secured in place. The patient tolerated the procedure well and was to the recovery room in satisfactory condition.
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DESCRIPTION: Transforaminal lumbar interbody fusion, placement of intervertebral prosthetic device.

orthopedic, degenerative disk disease, disk protrusions, spondylosis, radiculopathy, tlif, transforaminal lumbar interbody fusio, danek m8, intervertebral prosthetic device, danek capstone, matchstick burr, capstone, bmp, vertebral autograft, screws were placed bilaterally, pedicle screw, kerrison rongeurs, disk space, disk, spacers, kerrison, interbody, rongeurs, pedicle, lumbar, screws,

The scenario describes a detailed surgical procedure involving a Transforaminal Lumbar Interbody Fusion (TLIF), which is a common yet complex surgery in orthopedic and neurosurgical practices. The stakes are relatively high due to several factors: the complexity of the procedure, the potential for serious complications if something were to go wrong, and the implications for the patient's mobility and quality of life. However, no immediate complications were reported, and the procedure was deemed successful, which reduces the immediate urgency. Nonetheless, given the critical nature of spinal surgeries, this remains a high-stakes situation.


Medical Specialty: Hematology - Oncology
Sample Name: Craniopharyngioma - Postop

REASON FOR VISIT:,  Postoperative visit for craniopharyngioma.,HISTORY OF PRESENT ILLNESS:,  Briefly, a 16-year-old right-handed boy who is in eleventh grade, who presents with some blurred vision and visual acuity difficulties, was found to have a suprasellar tumor.  He was brought to the operating room on 01/04/07, underwent a transsphenoidal resection of tumor.  Histology returned as craniopharyngioma.  There is some residual disease; however, the visual apparatus was decompressed.  According to him, he is doing well, back at school without any difficulties.  He has some occasional headaches and tinnitus, but his vision is much improved.,MEDICATIONS: , Synthroid 100 mcg per day.,FINDINGS: , On exam, he is awake, alert and oriented x 3.  Pupils are equal and reactive.  EOMs are full.  His visual acuity is 20/25 in the right (improved from 20/200) and the left is 20/200 improved from 20/400.  He has a bitemporal hemianopsia, which is significantly improved and wider.  His motor is 5 out of 5.  There are no focal motor or sensory deficits.  The abdominal incision is well healed.  There is no evidence of erythema or collection.  The lumbar drain was also well healed.,The postoperative MRI demonstrates small residual disease.,Histology returned as craniopharyngioma.,ASSESSMENT: , Postoperative visit for craniopharyngioma with residual disease.,PLANS: , I have recommended that he call.  I discussed the options with our radiation oncologist, Dr. X. They will schedule the appointment to see him.  In addition, he probably will need an MRI prior to any treatment, to follow the residual disease.
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DESCRIPTION: Postoperative visit for craniopharyngioma with residual disease.  According to him, he is doing well, back at school without any difficulties.  He has some occasional headaches and tinnitus, but his vision is much improved.

hematology - oncology, visual acuity, blurred vision, tinnitus, headaches, residual disease, tumor, histology, craniopharyngioma,

The situation involves a postoperative visit for a 16-year-old boy with residual craniopharyngioma, a type of brain tumor. Postoperative care, especially for brain tumors, is critical. Although the patient is currently doing well, there is still residual disease, and further treatment, likely involving radiation oncologists, is being considered. This situation is relatively high-stakes due to the need for careful monitoring and follow-up to prevent potential complications and ensure effective treatment of the remaining disease.


Medical Specialty: Speech - Language
Sample Name: Speech Therapy Evaluation

MEDICAL DIAGNOSIS:,  Strokes.,SPEECH AND LANGUAGE THERAPY DIAGNOSIS:  ,Global aphasia.,SUBJECTIVE:  ,The patient is a 44-year-old female who is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.  The patient's sister-in-law was present throughout this assessment and provided all the patient's previous medical history.  Based on the sister-in-law's report, the patient had a stroke on 09/19/08.  The patient spent 6 weeks at XY Medical Center, where she was subsequently transferred to XYZ for therapy for approximately 3 weeks.  ABCD brought the patient to home the Monday before Thanksgiving, because they were not satisfied with the care the patient was receiving at a skilled nursing facility in Tucson.  The patient's previous medical history includes a long history of illegal drug use to include cocaine, crystal methamphetamine, and marijuana.  In March of 2008, the patient had some type of potassium issue and she was hospitalized at that time.  Prior to the stroke, the patient was not working and ABCD reported that she believes the patient completed the ninth grade, but she did not graduate from high school.  During the case history, I did pose several questions to the patient, but her response was often "no."  She was very emotional during this evaluation and crying occurred multiple times.,OBJECTIVE:  ,To evaluate the patient's overall communication ability, a Western Aphasia Battery was completed.  Also tests were not done due to time constraint and the patient's severe difficulty and emotional state.  Speech automatic tests were also completed to determine if the patient had any functional speech.,ASSESSMENT:,  Based on the results of the Weston aphasia battery, the patient's deficits most closely resemble global aphasia.  On the spontaneous speech subtest, the patient responded "no" to all questions asked except for how are you today where she gave a thumbs-up.  She provided no responses to picture description task and it is unclear if the patient was unable to follow the direction or if she was unable to see the picture clearly.  The patient's sister-in-law did state that the patient wore glasses, but she currently does not have them and she did not know the extent the patient's visual deficit.,On the auditory verbal comprehension portion of the Western Aphasia Battery, the patient answered "no" to all "yes/no" questions.  The auditory word recognition subtest, the patient had 5 out of 60 responses correct.  With the sequential command, she had 10 out of 80 corrects.  She was able to shut her eyes, point to the window, and point to the pen after directions.  With repetition subtest, she repeated bed correctly, but no other stimuli.  At this time, the patient became very emotional and repeatedly stated "I can't".  During the naming subtest of the Western Aphasia Battery, the patient's responses contained numerous paraphasias and her speech was often unintelligible due to jargon.  The word fluency test was not administered and the patient scored 2 out of 10 on the sentence completion task and 0 out of 10 on the responsive speech.  In regards to speech automatics, the patient is able to count from 1 to 9 accurately; however, stated 7 instead of 10 at the end of the task.  She is not able to state the days of the week or months in the year or her name at this time.  She cannot identify the day on calendar and was unable to verbally state the date or month.,DIAGNOSTIC IMPRESSION:  ,The patient's communication deficits most closely resemble global aphasia where she has difficulty with both receptive as well as expressive communication.  She does perseverate and is very emotional due to probable frustration.  Outpatient skilled speech therapy is recommended to improve the patient's functional communication skills.,PATIENT GOAL: , Her sister-in-law stated that they would like to improve upon the patient's speech to allow her to communicate more easily at home.,PLAN OF CARE: , Outpatient skilled speech therapy two times a week for the next 12 weeks.  Therapy to include aphasia treatment and home activities.,SHORT-TERM GOALS (8 WEEKS):,1.  The patient will answer simple "yes/no" questions with greater than 90% accuracy with minimal cueing.,2.  The patient will be able to complete speech automatic tasks with greater than 80% accuracy without models or cueing.,3.  The patient will be able to complete simple sentence completion and/or phrase completion with greater than 80% accuracy with minimal cueing.,4.  The patient will be able to follow simple one-step commands with greater than 80% accuracy with minimal cueing.,5.  The patient will be able to name 10 basic everyday objects with greater than 80% accuracy with minimal cueing.,SHORT-TERM GOALS (12 WEEKS):,  Functional communication abilities to allow the patient to express her basic wants and needs.
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DESCRIPTION: Global aphasia.  The patient is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.

speech - language, speech automatic tasks, minimal cueing, sentence completion, western aphasia battery, skilled speech therapy, global aphasia, speech therapy, speech, aphasia,

This situation involves a patient with global aphasia following a stroke requiring skilled speech therapy to improve communication abilities. While it is serious and impacts quality of life, it is not immediately life-threatening. The stakes are related to the patient's potential for functional recovery and improvement in daily life communication, which is crucial for quality of life but not critical for survival. Thus, it is important but not extremely high-stakes.


Medical Specialty: Radiology
Sample Name: Ultrasound OB - 1

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

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

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


Medical Specialty: Surgery
Sample Name: Endotracheal Intubation - 1

PROCEDURE PERFORMED: , Endotracheal intubation.,INDICATION FOR PROCEDURE:  ,The patient was intubated secondary to respiratory distress and increased work of breathing and falling saturation on 15 liters nonrebreather.  PCO2 was 29 and pO2 was 66 on the 15 liters.,NARRATIVE OF PROCEDURE: , The patient was given a total of 5 mg of Versed, 20 mg of etomidate, and 10 mg of vecuronium.  He was intubated in a single attempt.  Cords were well visualized, and a #8 endotracheal tube was passed using a curved blade.  Fiberoptically, a bronchoscope was passed for lavage and the tube was found to be in good position 3 cm above the main carina where it was kept there and the right lower lobe was lavaged with trap A lavage with 100 mL of normal sterile saline for cytology, AFB, and fungal smear and culture.  A separate trap B was then lavaged for bacterial C&S and Gram stain and was sent for those purposes.  The patient tolerated the procedure well.
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DESCRIPTION: Endotracheal intubation.  The patient was intubated secondary to respiratory distress and increased work of breathing and falling saturation on 15 liters nonrebreather.  PCO2 was 29 and pO2 was 66 on the 15 liters.

surgery, nonrebreather, respiratory distress, falling saturation, endotracheal intubation, lavage, breathingNOTE

Endotracheal intubation is a high-stakes procedure as it is required in critical situations where a patient's airway needs to be secured due to respiratory distress. The described scenario indicates that the patient was experiencing severe respiratory issues, with falling oxygen saturation levels, necessitating immediate intervention. The details of medication and tools used, as well as the focus on the intubation's success, underscore the life-critical nature of the procedure. The success or failure of this procedure can directly impact the patient's survival, making it high-stakes.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Heart Catheterization, Ventriculography, & Angiography - 6

PREOPERATIVE DIAGNOSES,1.  Dyspnea on exertion with abnormal stress echocardiography.,2.  Frequent PVCs.,3.  Metabolic syndrome.,POSTOPERATIVE DIAGNOSES,1.  A 50% distal left main and two-vessel coronary artery disease with normal left ventricular systolic function.,2.  Frequent PVCs.,3.  Metabolic syndrome.,PROCEDURES,1.  Left heart catheterization with left ventriculography.,2.  Selective coronary angiography.,COMPLICATIONS: , None.,DESCRIPTION OF PROCEDURE: , After informed consent was obtained, the patient was brought to the Cardiac Catheterization Laboratory in fasting state.  Both groins were prepped and draped in the usual sterile fashion.  Xylocaine 1% was used as local anesthetic.  Versed and fentanyl were used for conscious sedation.  Next, a #6-French sheath was placed in the right femoral artery using modified Seldinger technique.  Next, selective angiography of the left coronary artery was performed in multiple views using #6-French JL4 catheter.  Next, selective angiography of the right coronary artery was performed in multiple views using #6-French 3DRC catheter.  Next, a #6-French angle pigtail catheter was advanced into the left ventricle.  The left ventricular pressure was then recorded.  Left ventriculography was the performed using 36 mL of contrast injected over 3 seconds.  The left heart pull back was then performed.  The catheter was then removed.,Angiography of the right femoral artery was performed.  Hemostasis was obtained by Angio-Seal closure device.  The patient left the Cardiac Catheterization Laboratory in stable condition.,HEMODYNAMICS,1.  LV pressure was 163/0 with end-diastolic pressure of 17.  There was no significant gradient across the aortic valve.,2.  Left ventriculography showed old inferior wall hypokinesis.  Global left ventricular systolic function is normal.  Estimated ejection fraction was 58%.  There is no significant mitral regurgitation.,3.  Significant coronary artery disease.,4.  The left main is approximately 7 or 8 mm proximally.  It trifurcates into left anterior descending artery, ramus intermedius artery, and left circumflex artery.  The distal portion of the left main has an ulcerated excentric plaque, up to about 50% in severity.,5.  The left anterior descending artery is around 4 mm proximally.  It extends slightly beyond the apex into the inferior wall.  It gives rises to several medium size diagonal branches as well as small to medium size multiple septal perforators.  At the ostium of the left anterior descending artery, there was an eccentric plaque up to 70% to 80%, best seen in the shallow LAO with caudal angulation.,There was no other flow-limiting disease noted in the rest of the left anterior descending artery or its major branches.,The ramus intermedius artery is around 3 mm proximally, but shortly after its origin, it bifurcates into two medium size branches.  There was no significant disease noted in the ramus intermedius artery however.,The left circumflex artery is around 2.5 mm proximally.  It gave off a recurrent atrial branch and a small AV groove branch prior to terminating into a bifurcating medium size obtuse marginal branch.  The mid to distal circumflex has a moderate disease, which is relatively diffuse up to about 40% to 50%.,The right coronary artery is around 4 mm in diameter.  It gives off conus branch, two medium size acute marginal branches, relatively large posterior descending artery and a posterior lateral branch.  In the mid portion of the right coronary artery at the origin of the first acute marginal branch, there is a relatively discrete stenosis of about 80% to 90%.  Proximally, there is an area of eccentric plaque, but seem to be non-flow limiting, at best around 20% to 30%.  Additionally, there is what appears to be like a shell-like lesion in the proximal segment of the right coronary artery as well.  The posterior descending artery has an eccentric plaque of about 40% to 50% in its mid segment.,PLAN:  ,Plan to consult cardiovascular surgery for consideration of coronary artery bypass surgery.  Continue risk factor modification, aspirin, and beta blocker.
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DESCRIPTION: Left heart catheterization with left ventriculography and selective coronary angiography.  A 50% distal left main and two-vessel coronary artery disease with normal left ventricular systolic function.  Frequent PVCs.  Metabolic syndrome.

cardiovascular / pulmonary, heart catheterization, ventriculography, coronary angiography, dyspnea, metabolic syndrome, two-vessel coronary artery disease, echocardiography, selective coronary angiography, anterior descending artery, branches, coronary, angiography, artery, catheterization,

The situation described pertains to a complex medical procedure involving heart catheterization, ventriculography, and angiography. The patient has multiple preoperative diagnoses, including dyspnea, frequent PVCs, and metabolic syndrome, and the postoperative findings confirmed significant coronary artery disease. The decision to consult cardiovascular surgery for potential coronary artery bypass surgery indicates a high-stakes situation as it involves critical decisions impacting the patient's cardiac health and potential surgical intervention. The absence of immediate complications during the procedure is positive, yet the underlying health challenges and subsequent treatment decisions make the stakes higher than routine medical check-ups or treatments.


Medical Specialty: Orthopedic
Sample Name: Lumbar Discectomy - Microscopic

PREOPERATIVE DIAGNOSES:,1.  Extruded herniated disc, left L5-S1.,2.  Left S1 radiculopathy (acute).,3.  Morbid obesity.,POSTOPERATIVE DIAGNOSES:,1.  Extruded herniated disc, left L5-S1.,2.  Left S1 radiculopathy (acute).,3.  Morbid obesity.,PROCEDURE PERFORMED: , Microscopic lumbar discectomy, left L5-S1.,ANESTHESIA: , General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:  ,50 cc.,HISTORY: , This is a 40-year-old female with severe intractable left leg pain from a large extruded herniated disc at L5-S1.  She has been dealing with these symptoms for greater than three months.  She comes to my office with severe pain, left my office and reported to the Emergency Room where she was admitted for pain control one day before surgery.  I have discussed the MRI findings with the patient and the potential risks and complications.  She was scheduled to go to surgery through my office, but because of her severe symptoms, she was unable to keep that appointment and reported right to the Emergency Room.  We discussed the diagnosis and the operative procedure in detail.  I have reviewed the potential risks and complications and she had agreed to proceed with the surgery.  Due to the patient's weight which exceeds 340 lb, there was some concern about her operative table being able to support her weight and also my standard microlumbar discectomy incision is not ________ in this situation just because of the enormous size of the patient's back and abdomen and I have discussed this with her.  She is aware that she will have a much larger incision than what is standard and has agreed to accept this.,OPERATIVE PROCEDURE:  ,The patient was taken to OR #5 at ABCD General Hospital.  While in the hospital gurney, Department of Anesthesia administered general anesthetic, endotracheal intubation was followed.  A Jackson table was prepared for the patient and was reinforced replacing struts under table to prevent the table from collapsing.  The table reportedly does have a limit of 500 lb, but the table has never been stressed above 275 lb.  Once the table was reinforced, the patient was carefully rolled in a prone position on the Jackson table with the bony prominences being well padded.  A marker was placed in from the back at this time and an x-ray was obtained for incision localization.  The back is now prepped and draped in the usual sterile fashion.  A midline incision was made over the L5-S1 disc space taking through subcutaneous tissue sharply with a #10 Bard-Parker scalpel.  The lumbar dorsal fascia was then encountered and incised to the left of midline.  In the subperiosteal fashion, the musculature was elevated off the lamina at L5 and S1 after facet joint, but not disturbing the capsule.  A second marker was now placed and an intraoperative x-ray confirms our location at the L5-S1 disc space.  The microscope was brought into the field at this point and the remainder of the procedure done with microscopic visualization and illumination.  A high speed drill was used to perform a laminotomy by removing small portion of the superior edge of the S1 lamina and the inferior edge of the L5 lamina.  Ligaments and fragments were encountered and removed at this time.  The epidural space was now encountered.  The S1 nerve root was now visualized and found to be displaced dorsally as a result of a large disc herniation while the nerve was carefully protected with a Penfield.  A small stab incision was made into the disc fragment and probably a large portion of disc extrudes from the opening.  This disc fragment was removed and the nerve root was much more supple, it was carefully retracted.  The nerve root was now retracted and using a series of downgoing curettes, additional disc material was removed from around the disc space and from behind the body of S1 and L5.  At this point, all disc fragments were removed from the epidural space.  Murphy ball was passed anterior to the thecal sac in the epidural space and there was no additional compression that I can identify.  The disc space was now encountered and loose disc fragments were removed from within the disc space.  The disc space was then irrigated.  The nerve root was then reassessed and found to be quite supple.  At this point, the Murphy ball was passed into the foramen of L5 and this was patent and also into the foramen of S1 by passing ventral and dorsal to the nerve root and there were no obstructions in the passage of the device.  At this point, the wound was irrigated copiously and suctioned dry.  Gelfoam was used to cover the epidural space.  The retractors were removed at this point.  The fascia was reapproximated with #1 Vicryl suture, subcutaneous tissue with #2-0 Vicryl suture and Steri-Strips for curved incision.  The patient was transferred to the hospital gurney in supine position and extubated by Anesthesia, subsequently transferred to Postanesthesia Care Unit in stable condition.
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DESCRIPTION: Microscopic lumbar discectomy, left L5-S1.   Extruded herniated disc, left L5-S1.  Left S1 radiculopathy (acute). Morbid obesity.

orthopedic, extruded herniated disc, radiculopathy, microscopic, lumbar, discectomy, lumbar discectomy, morbid obesity, herniated disc, epidural space, nerve root, disc space, space, intractable, lamina, epidural, incision, nerve, herniated,

The situation involves a surgical procedure, specifically a lumbar discectomy, which is inherently a high-stakes scenario due to the potential risks and need for precision in the procedure. Furthermore, factors such as the patient's morbid obesity and acute symptoms add complexity and potential for complications. While the surgery was completed without complications and the patient's post-operative condition was stable, the nature of surgical interventions naturally elevates the stakes due to the criticality of the procedure and the impact on patient health.


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

Medical Specialty: Cosmetic / Plastic Surgery
Sample Name: Belly Button Piercing

PROCEDURE:,  Belly button piercing for insertion of belly button ring.,DESCRIPTION OF PROCEDURE:,  The patient was prepped after informed consent was given of risk of infection and foreign body reaction.  The area was marked by the patient and then prepped.  The area was injected with 2% Xylocaine 1:100,000 epinephrine.,Then a #14-gauge needle was inserted above the belly button and inserted up to the skin just above the actual umbilical area and the ring was inserted into the #14-gauge needle and pulled through.  A small ball was placed over the end of the ring.  This terminated the procedure.,The patient tolerated the procedure well.  Postop instructions were given regarding maintenance.  Patient left the office in satisfactory condition.
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DESCRIPTION: Belly button piercing for insertion of belly button ring.

cosmetic / plastic surgery, belly button piercing, 2% xylocaine, belly button, postop instructions, the patient tolerated the procedure well, foreign body, gauge needle, needle, piercing, ring, satisfactory condition, umbilical, button piercing, belly, buttonNOTE

The procedure described is a belly button piercing, which is typically considered a low-risk cosmetic procedure. The stakes involved are low because the procedure is minimally invasive and generally performed without significant risk to the patient's health. Even though informed consent regarding risks like infection is given, these risks are minor compared to those associated with more invasive surgical procedures. The patient's tolerance of the procedure and satisfactory condition upon leaving further indicate low stakes.


Medical Specialty: Consult - History and Phy.
Sample Name: Request For Consultation

REASON FOR CONSULTATION:, Please evaluate stomatitis, possibly methotrexate related.,HISTORY OF PRESENT ILLNESS:, The patient is a very pleasant 57-year old white female, a native of Cuba, being seen for evaluation and treatment of sores in her mouth that she has had for the last 10-12 days.  The patient has a long history of severe and debilitating rheumatoid arthritis for which she has had numerous treatments, but over the past ten years she has been treated with methotrexate quite successfully.  Her dosage has varied somewhere between 20 and 25 mg per week.  About the beginning of this year, her dosage was decreased from 25 mg to 20 mg, but because of the flare of the rheumatoid arthritis, it was increased to 22.5 mg per week.  She has had no problems with methotrexate as far as she knows.  She also took an NSAID about a month ago that was recently continued because of the ulcerations in her mouth.  About two weeks ago, just about the time the stomatitis began she was placed on an antibiotic for suspected upper respiratory infection.  She does not remember the name of the antibiotic.  Although she claims she remembers taking this type of medication in the past without any problems.  She was on that medication three pills a day for three to four days.  She notes no other problems with her skin.  She remembers no allergic reactions to medication.  She has no previous history of fever blisters.  ,PHYSICAL EXAMINATION:, Reveals superficial erosions along the lips particularly the lower lips.  The posterior buccal mucosa along the sides of the tongue and also some superficial erosions along the upper and lower gingiva.  Her posterior pharynx was difficult to visualize, but I saw no erosions on the areas today.  There did however appear to be one small erosion on the soft palate.  Examination of the rest of her skin revealed no areas of dermatitis or blistering.  There were some macular hyperpigmentation on the right arm where she has had a previous burn, plus the deformities from her rheumatoid arthritis on her hands and feet as well as scars on her knees from total joint replacement surgeries.  ,IMPRESSION: , Erosive stomatitis probably secondary to methotrexate even though the medication has been used for ten years without any problems.  Methotrexate may produce an erosive stomatitis and enteritis after such a use. The patient also may have an enteritis that at this point may have become more quiescent as she notes that she did have some diarrhea about the time her mouth problem developed. She has had no diarrhea today, however. She has noted no blood in her stools and has had no episodes of nausea or vomiting.  ,I am not as familiar with the NSAID causing an erosive stomatitis.  I understand that it can cause gastrointestinal upset, but given the choice between the two, I would think the methotrexate is the most likely etiology for the stomatitis.  ,RECOMMENDED THERAPY: ,I agree with your therapeutic regimen regarding this condition with the use of prednisone and folic acid.  I also agree that the methotrexate must be discontinued in order to produce a resolution of this patients’ skin problem. However, in my experience, this stomatitis may take a number of weeks to go away completely if a patient been on methotrexate, for an extended period of time, because the medication is stored within the liver and in fatty tissue.  Topically I have prescribed Lidex gel, which I find works extremely well in stomatitis conditions.  It can be applied t.i.d.  ,Thank you very much for allowing me to share in the care of this pleasant patient.  I will follow her with you as needed.
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DESCRIPTION: Request for consultation to evaluate stomatitis, possibly methotrexate related.

consult - history and phy., stomatitis, nsaid, blistering, blisters, buccal mucosa, dermatitis, erosive stomatitis, gastrointestinal, methotrexate, mouth, rheumatoid arthritis, stomatitis conditions, superficial erosions, upper respiratory infection, illness, medication

The situation involves a consultation regarding a 57-year old patient experiencing stomatitis, suspected to be related to methotrexate use. Methotrexate, used for managing rheumatoid arthritis, can cause serious side effects, including erosive stomatitis. This consultation aims to manage the patient's symptoms and adjust her medication. While stomatitis can be painful and unpleasant, this scenario does not involve immediate life-threatening conditions. It does require careful management to prevent further complications due to the patient's long-term medication use, but the situation is stable with recommendations for treatment given.


Medical Specialty: Orthopedic
Sample Name: Rotator cuff syndrome - H&P

CHIEF COMPLAINT:  ,This 18 year old male presents today with shoulder pain right.  Location:  He indicates the problem location is the right shoulder diffusely.  Quality:  Quality of the pain is described by the patient as aching, throbbing and tolerable.  Patient relates pain on a scale from 0 to 10 as 5/10.  Severity:  The severity has worsened over the past 3 months.  Timing (onset/frequency):  Onset was gradual and after pitching a baseball game.  Modifying Factors:  Patient's condition is aggravated by throwing.  He participates with difficulty in basketball.  Past conservative treatments include NSAID and muscle relaxant medications.,ALLERGIES: , No known medical allergies.,MEDICATION HISTORY:,  None.,PAST MEDICAL HISTORY:  ,Childhood Illnesses: (+) strep throat (+) mumps (+) chickenpox,PAST SURGICAL HISTORY:,  No previous surgeries.,FAMILY HISTORY:,  Patient admits a family history of arthritis associated with mother.,SOCIAL HISTORY: , Patient denies smoking, alcohol abuse, illicit drug use and STDs.,REVIEW OF SYSTEMS:,Musculoskeletal: (+) joint or musculoskeletal symptoms (+) stiffness in AM.,Psychiatric: (-) psychiatric or emotional difficulties.,Eyes: (-) visual disturbance or change.,Neurological: (-) neurological symptoms or problems Endocrine: (-) endocrine-related symptoms.,Allergic / Immunologic: (-) allergic or immunologic symptoms.,Ears, Nose, Mouth, Throat: (-) symptoms involving ear, nose, mouth, or throat.,Gastrointestinal: (-) GI symptoms.,Genitourinary: (-) GU symptoms.,Constitutional Symptoms: (-) constitutional symptoms such as fever, headache, nausea, dizziness.,Cardiovascular: (-) cardiovascular problems or chest symptoms.,Respiratory: (-)breathing difficulties, respiratory symptoms.,Physical Exam:  BP Standing:  116/68 Resp:  16 HR:  68 Temp:  98.1 Height:  5 ft.  11 in.  Weight:  165 lbs.  Patient is a 18 year old male who appears pleasant, in no apparent distress, his given age, well developed, well nourished and with good attention to hygiene and body habitus.  Oriented to person, place and time.  Right shoulder shows evidence of swelling and tenderness.  Radial pulses are 2 /4, bilateral.  Brachial pulses are 2 /4, bilateral.,Appearance:  Normal.,Tenderness:  Anterior - moderate, Biceps - none, Posterior - moderate and Subacromial - moderate right.,Range of Motion:  Right shoulder ROM shows decreased flexion, decreased extension, decreased adduction, decreased abduction, decreased internal rotation, decreased external rotation.  L shoulder normal.,Strength:  External rotation - fair.  Internal rotation - poor right.,AC Joint:  Pain with ABD and cross-chest - mild right.,Rotator Cuff:  Impingement - moderate.  Painful arc - moderate right.,Instability:  None.,TEST & X-RAY RESULTS:,  X-rays of the shoulder were performed.  X-ray of right shoulder reveals cuff arthropathy present.,IMPRESSION: , Rotator cuff syndrome, right.,PLAN: , Diagnosis of a rotator cuff tendinitis and shoulder impingement were discussed.  I noted that this is a very common condition resulting in significant difficulties with use of the arm.  Several treatment options and their potential benefits were described.  Nonsteroidal anti-inflammatories can be helpful but typically are slow acting.  Cortisone shots can be very effective and are quite safe.  Often more than one injection may be required.  Physical therapy can also be helpful, particularly if there is any loss of shoulder mobility or strength.  If these treatments fail to resolve symptoms, an MRI or shoulder arthrogram may be required to rule out a rotator cuff tear.  Injected shoulder joint and with Celestone Soluspan 1.0 cc .  Ordered x-rays of shoulder right.,PRESCRIPTIONS:,  Vioxx Dosage:  25 mg tablet Sig:  TID Dispense:  60 Refills:  0 Allow Generic:  Yes,PATIENT INSTRUCTIONS:,  Patient was instructed to restrict activity.  Patient was given instructions on RICE therapy.
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DESCRIPTION: Shoulder pain, right shoulder diffusely - Rotator cuff syndrome, right.

The 18-year-old patient is experiencing a common yet uncomfortable condition, rotator cuff syndrome, which is causing shoulder pain and limiting his athletic activities. Although the patient is in pain, the condition is not life-threatening and typically responds well to treatment such as NSAIDs, cortisone injections, and physical therapy. Additionally, the situation does not involve immediate risk to the patient's overall health, career, or life, which indicates it is not high-stakes.