Medical Specialty: Neurology
Sample Name: MRI C-spine

CC:, Left hemibody numbness.,HX:, This 44y/o RHF awoke on 7/29/93 with left hemibody numbness without tingling, weakness, ataxia, visual or mental status change. She had no progression of her symptoms until 7/7/93 when she notices her right hand was stiff and clumsy. She coincidentally began listing to the right when walking. She denied any recent colds/flu-like illness or history of multiple sclerosis. She denied symptoms of Lhermitte's or Uhthoff's phenomena.,MEDS:, none.,PMH:, 1)Bronchitis twice in past year (last 2 months ago).,FHX:, Father with HTN and h/o strokes at ages 45 and 80; now 82 years old. Mother has DM and is age 80.,SHX:, Denies Tobacco/ETOH/illicit drug use.,EXAM:, BP112/76 HR52 RR16 36.8C,MS: unremarkable.,CN: unremarkable.,Motor: 5/5 strength throughout except for slowing of right hand fine motor movement. There was mildly increased muscle tone in the RUE and RLE.,Sensory: decreased PP below T2 level on left and some dysesthesias below L1 on the left.,Coord: positive rebound in RUE.,Station/Gait: unremarkable.,Reflexes: 3+/3 throughout all four extremities. Plantar responses were flexor, bilaterally.,Rectal exam not done.,Gen exam reportedly "normal.",COURSE:, GS, CBC, PT, PTT, ESR, Serum SSA/SSB/dsDNA, B12 were all normal. MRI C-spine, 7/145/93, showed an area of decreased T1 and increased T2 signal at the C4-6 levels within the right lateral spinal cord. The lesion appeared intramedullary and eccentric, and peripherally enhanced with gadolinium. Lumbar puncture, 7/16/93, revealed the following CSF analysis results: RBC 0, WBC 1 (lymphocyte), Protein 28mg/dl, Glucose 62mg/dl, CSF Albumin 16 (normal 14-20), Serum Albumin 4520 (normal 3150-4500), CSF IgG 4.1mg/dl (normal 0-6.2), CSF IgG, % total CSF protein 15% (normal 1-14%), CSF IgG index 1.1 (normal 0-0.7), Oligoclonal bands were present. She was discharged home.,The patient claimed her symptoms resolved within one month. She did not return for a scheduled follow-up MRI C-spine.
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DESCRIPTION: MRI C-spine: C4-5 Transverse Myelitis.

MRI C-spine: C4-5 Transverse Myelitis.

neurology, mri c-spine, c-spine, lhermitte's, myelitis, transverse myelitis, uhthoff's, ataxia, clumsy, hemibody numbness, mental status, numbness, tingling, weakness, mri c spine, hemibody, mri, spine, csf,

The patient reported significant neurological symptoms such as left hemibody numbness and later right hand stiffness, alongside findings from the MRI suggesting transverse myelitis. Given the spinal cord involvement, there is potential for serious outcomes, like permanent neurological deficits, if not managed correctly. However, the symptoms resolved within a month, indicating the situation might not have been life-threatening. The medical history, family history of strokes, and the lack of follow-up could potentially indicate a risk that might be underestimated. The stakes are moderate given the potential severity of untreated or recurring neurological symptoms.


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Medical Specialty: Dentistry
Sample Name: Extraoral I&D

PREOPERATIVE DIAGNOSIS:,  Left masticator space infection secondary to necrotic tooth #17.,POSTOPERATIVE DIAGNOSIS: , Left masticator space infection secondary to necrotic tooth #17.,SURGICAL PROCEDURE:,  Extraoral incision and drainage of facial space infection and extraction of necrotic tooth #17.,FLUIDS:  ,500 mL of crystalloid.,ESTIMATED BLOOD LOSS: , 60 mL.,SPECIMENS:,  Cultures and sensitivities, Aerobic and anaerobic were sent for micro studies.,DRAINS:,  One 0.25-inch Penrose placed in the medial aspect of the masticator space.,CONDITION: , Good, extubated, breathing spontaneously, to PACU.,INDICATIONS FOR PROCEDURE:  ,The patient is a 26-year-old Caucasian male with a 2-week history of a toothache and 5-day history of increasing swelling of his left submandibular region, presents to Clinic, complaining of difficulty swallowing and breathing.  Oral surgery was consulted to evaluate the patient.,After evaluation of the facial CT with tracheal deviation and abscess in the left muscular space, it was determined that the patient needed to be taken urgently to the operating room under general anesthesia and have the abscess incision and drainage and removal of tooth #17.  Risks, benefits, alternatives, treatments were thoroughly discussed with the patient and consent was obtained.,DESCRIPTION OF PROCEDURE:,  The patient was transported to operating room #4 at Clinic.  He was laid supine on the operating room table.  ASA monitors were attached and general anesthesia was induced with IV anesthetics and maintained with oral endotracheal intubation and inhalation of anesthetics.  The patient was prepped and draped in the usual oral and maxillofacial surgery fashion.,The surgeon approached the operating room table in sterile fashion.  Approximately 2 mL of 1% lidocaine with 1:100,000 epinephrine were injected into the left submandibular area in the area of the incision.  After waiting appropriate time for local anesthesia to take effect, an 18-gauge needle was introduced into the left masticator space and approximately 5 mL of pus was removed.  This was sent for aerobic and anaerobic micro.  Using a 15-blade, a 2-cm incision was made in the left submandibular region, then a hemostat was introduced in blunt dissection into the medial border of the mandible was performed.  The left masticator space was thoroughly explored as well as the left submandibular space and submental space.  Pus was drained from this site.  Copious amounts of sterile fluid were irrigated into the site.,Attention was then directed intraorally where a moistened Ray-Tec sponge was placed in the posterior oropharynx to act as a throat pack.  Approximately 4 mL of 1% lidocaine with 1:100,000 epinephrine were injected into the left inferior alveolar nerve block.  Using a 15-blade, a full-thickness mucoperiosteal flap was developed around tooth #17.  The tooth was elevated and delivered, and the lingual area of tooth #17 was explored and more pus was expressed.  This pus was evacuated intraorally __________ suction.  The extraction site and the left masticator space were irrigated, and it was noted that the irrigation was communicating with extraoral incision in the neck.,A 0.25-inch Penrose drain was placed in the lingual aspect of the mandible extraorally through the neck and secured with 2-0 silk suture.  A tack stitch intraorally with 3-0 chromic suture was placed.  The throat pack was then removed.  An orogastric tube was placed and removed all other stomach contents and then removed.  At this point, the procedure was then determined to be over.  The patient was extubated, breathing spontaneously, and transported to PACU in good condition.
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DESCRIPTION: Left masticator space infection secondary to necrotic tooth #17.  Extraoral incision and drainage of facial space infection and extraction of necrotic tooth #17.

dentistry, masticator space infection, extraoral, incision and drainage, ray-tec sponge, submandibular, space infection, necrotic tooth, masticator space, space, drainage, necrotic, incision, masticator, tooth,

This situation involves a surgical procedure to address a significant facial infection, which has led to complications like difficulty swallowing and breathing, indicating that it was urgent and potentially life-threatening. Such infections can lead to serious complications, including airway obstruction or spread of infection. The situation also involves general anesthesia, which carries its own risks. Therefore, the stakes of this situation are reasonably high.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Nephrology
Sample Name: Nephrectomy - Transplant

PREOPERATIVE DIAGNOSIS: , Rejection of renal transplant.,POSTOPERATIVE DIAGNOSIS: , Rejection of renal transplant.,OPERATIVE PROCEDURE: , Transplant nephrectomy.,DESCRIPTION OF PROCEDURE: , The patient has had rapid deterioration of her kidney function since her transplant at ABCD one year ago.  The patient was recently thought to have obstruction to the transplant and a stent was placed in to the transplant percutaneously, but the ureter was wide open and there was no evidence of obstruction.  Because the kidney was felt to be irretrievably lost and immunosuppression had been withdrawn, it was elected to go ahead and remove the kidney and hopes that her fever and toxic course could be arrested.,With the patient in the supine position, the previously placed nephrostomy tube was removed.  The patient then after adequate prepping and draping, and placing of a small roll under the right hip, underwent an incision in the direction of the transplant incision down through and through all muscle layers and into the preperitoneal space.  The kidney was encountered and kidney was dissected free of its attachments through the retroperitoneal space.  During the course of dissection, the iliac artery and vein were identified as was the native ureter and the patient's ilioinguinal nerve; all these were preserved.  The individual vessels in the kidney were identified, ligated, and incised, and the kidney was removed.  The ureter was encountered during the course of resection, but was not ligated.  The patient's retroperitoneal space was irrigated with antibiotic solution and #19 Blake drain was placed into the retroperitoneal space, and the patient returned to the recovery room in good condition.,ESTIMATED BLOOD LOSS:  900 mL.
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DESCRIPTION: Transplant nephrectomy after rejection of renal transplant

nephrology, renal transplant, blake drain, rejection, iliac artery, ilioinguinal, immunosuppression, kidney function, nephrectomy, nephrostomy tube, retroperitoneal space, toxic, ureter, vein, transplant, renal, retroperitoneal, kidney,

The situation involves a nephrectomy due to rejection of a renal transplant. This is a significant surgical procedure with potential for serious complications, including managing post-surgical infections, blood loss (with an estimated blood loss of 900 mL in this case), and the need for future dialysis or retransplant. The rejection of a transplanted organ is also a significant medical event, impacting the patient's health and quality of life considerably. Additionally, there is mention of previous deterioration and interventions that were not successful, highlighting the critical nature of this surgical intervention.


Medical Specialty: Neurology
Sample Name: Consult - Migraine

HISTORY OF PRESENT ILLNESS: , The patient is a 36-year-old female with past medical history of migraine headaches, who was brought to the ER after she was having uncontrolled headaches.  In the ER, the patient had a CT scan done, which was reported negative, and lumbar puncture with normal pressure and the cell count, and was admitted for followup.  Neurology consult was called to evaluate the patient in view of the current symptomatology.  The headaches were refractory to the treatment.  The patient has been on Topamax and Maxalt in the past, but did not work and according to the patient she got more confused.,PAST MEDICAL HISTORY: , History of migraine.,PAST SURGICAL HISTORY:  ,Significant for partial oophorectomy, appendectomy, and abdominoplasty.,SOCIAL HISTORY:  ,No history of any smoking, alcohol, or drug abuse.  The patient is a registered nurse by profession.,MEDICATIONS: , Currently taking no medication.,ALLERGIES: , No known allergies.,FAMILY HISTORY:,  Nothing significant.,REVIEW OF SYSTEMS: , The patient was considered to ask systemic review including neurology, psychiatry, sleep, ENT, ophthalmology, pulmonary, cardiology, gastroenterology, genitourinary, hematology, rheumatology, dermatology, allergy, immunology, endocrinology, toxicology, oncology, and was found to be positive for the symptoms mentioned in the history of the presenting illness.,PHYSICAL EXAMINATION,VITAL SIGNS:  Blood pressure of 115/66, heart rate of 69, respiratory rate of 13, temperature normal, and pulse oximetry 98% on room air at the time of initial evaluation.,HEENT:  Head, normocephalic, atraumatic.  Neck supple.  Throat clear.  No discharge from the ears or nose.  No discoloration of conjunctivae and sclerae.  No bruits auscultated over temple, orbits, or the neck.,LUNGS:  Clear to auscultation.,CARDIOVASCULAR:  Normal heart sounds.,ABDOMEN:  Benign.,EXTREMITIES:  No edema, clubbing or cyanosis.,SKIN:  No rash.  No neurocutaneous disorder.,MENTAL STATUS:  The patient is awake, alert and oriented to place and person.  Speech is fluent.  No language deficits.  Mood normal.  Affect is clear.  Memory and insight is normal.  No abnormality with thought processing and thought content.  Cranial nerve examination intact II through XII.  Motor examination:  Normal bulk, tone and power.  Deep tendon reflexes symmetrical.  Downgoing toes.  No sign of any myelopathy.  Cortical sensation intact.  Peripheral sensation grossly intact.  Vibratory sense not tested.  Gait not tested.  Coordination is normal with no dysmetria.,IMPRESSION: , Intractable headaches, by description to be migraines.  Complicated migraines by clinical criteria.  Rule out sinusitis.  Rule out vasculitis including temporal and arthritis, lupus, polyarthritis, moyamoya disease, Takayasu and Kawasaki disease.,PLAN AND RECOMMENDATIONS: , The patient to be given a trial of the prednisone with a plan to taper off in 6 days, as she already had received 50 mg today.  Depakote as a part of migraine prophylaxis and Fioricet on p.r.n. basis.,The patient to get vasculitis workup, as it has not been ordered by the primary care physician initially.  The patient already had MRI of the brain and the cervical spine.  MRI of the brain reported negative and cervical spine as shown signs of disk protrusion at C5 and C6 level, which will not explain of the temporal headache.  Plan and followup discussed with the patient in detail.
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DESCRIPTION: The patient is a 36-year-old female with past medical history of migraine headaches, who was brought to the ER after she was having uncontrolled headaches.  In the ER, the patient had a CT scan done, which was reported negative, and lumbar puncture with normal pressure and the cell count, and was admitted for followup.

The situation involves a patient with a history of migraines experiencing uncontrolled headaches, which are not responding to standard treatments. This required hospitalization and involvement of a neurology consult to explore further treatment options and possible underlying conditions such as vasculitis. While there is no immediate life-threatening condition identified in the current findings (e.g., the CT scan and lumbar puncture were negative), the persistence and complexity of the symptoms warrant thorough medical investigation and management to avoid potential complications. The stakes are moderate because the patient's quality of life is affected, and there is a need to explore and rule out other potentially serious conditions.


Medical Specialty: Podiatry
Sample Name: Symes Amputation - Hallux

PREOPERATIVE DIAGNOSES:,1.  Mass, left second toe.,2.  Tumor.,3.  Left hallux bone invasion of the distal phalanx.,POSTOPERATIVE DIAGNOSES:,1.  Mass, left second toe.,2.  Tumor.,3.  Left hallux with bone invasion of the distal phalanx.,PROCEDURE PERFORMED:,1.  Excision of mass, left second toe.,2.  Distal Syme's amputation, left hallux with excisional biopsy.,HISTORY: , This 47-year-old Caucasian male presents to ABCD General Hospital with a history of tissue mass on his left foot.  The patient states that the mass has been present for approximately two weeks and has been rapidly growing in size.  The patient also has history of shave biopsy in the past.  The patient does state that he desires surgical excision at this time.,PROCEDURE IN DETAIL:,  An IV was instituted by the Department of Anesthesia in the preoperative holding area.  The patient was transported from the operating room and placed on the operating room table in the supine position with the safety belt across his lap.  Copious amount of Webril was placed around the left ankle followed by a blood pressure cuff.  After adequate sedation by the Department of Anesthesia, a total of 6 cc mixed with 1% lidocaine plain with 0.5% Marcaine plain was injected in a digital block fashion at the base of the left hallux as well as the left second toe.,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.  Care was taken with the exsanguination to perform exsanguination below the level of the digits so as not to rupture the masses.  The foot was lowered to the operating table.  The stockinet was reflected and the foot was cleansed with wet and dry sponge.  A distal Syme's incision was planned over the distal aspect of the left hallux.  The incision was performed with a #10 blade and deepened with #15 down to the level of bone.  The dorsal skin flap was removed and dissected in toto off of the distal phalanx.  There was noted to be in growth of the soft tissue mass into the dorsal cortex with erosion in the dorsal cortex and exposure of cortical bone at the distal phalanx.  The tissue was sent to Pathology where Dr. Green stated that a frozen sample would be of less use for examining for cancer.  Dr. Green did state that he felt that there was an adequate incomplete excision of the soft tissue for specimen.  At this time, a sagittal saw was then used to resect all ends of bone of the distal phalanx.  The area was inspected for any remaining suspicious tissues.  Any suspicious tissue was removed.  The area was then flushed with copious amounts of sterile saline.  The skin was then reapproximated with #4-0 nylon with a combination of simple and vertical mattress sutures.,Attention was then directed to the left second toe.  There was noted to be a dorsolateral mass over the dorsal distal aspect of the left second toe.  A linear incision was made just medial to the tissue mass.  The mass was then dissected from the overlying skin and off of the underlying capsule.  This tissue mass was hard, round, and pearly-gray in appearance.  It does not invade into any other surrounding tissues.  The area was then flushed with copious amounts of sterile saline and the skin was closed with #4-0 nylon.  Dressings consisted of Owen silk soaked in Betadine, 4x4s, Kling, Kerlix, and an Ace wrap.  The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all five digits of the left foot.  The patient tolerated the above procedure and anesthesia well without complications.  The patient was transported to PACU with vital signs stable and vascular status intact.  The patient was given postoperative pain prescription for Vicodin and instructed to follow up with Dr. Bonnani in his office as directed.  The patient will be contacted immediately pending the results of pathology.  Cultures obtained in the case were aerobic and anaerobic gram stain, Silver stain, and a CBC.
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DESCRIPTION: Excision of mass, left second toe and distal Symes amputation, left hallux with excisional biopsy.  Mass, left second toe.  Tumor.  Left hallux bone invasion of the distal phalanx.

podiatry, distal phalanx, mass, tumor., hallux bone, phalanx, symes amputation, excisional biopsy, distal, amputation, invasion, toe, symes, incision, flushed, excision, tissue, hallux

The situation involves a surgical procedure for a rapidly growing mass suspected to be a tumor with bone invasion in the left toe of a patient. This is a significant and complex medical procedure, involving potential cancer diagnosis and the removal of part of the toe. Although not life-threatening in the immediate sense, the stakes are considerable due to the implications for the patient's health, quality of life, and the potential cancer diagnosis. There are also potential risks associated with the procedure, anesthesia, and recovery. These factors make it a relatively high-stakes medical situation.


Medical Specialty: Consult - History and Phy.
Sample Name: ER Report - Rib Cage Pain

HISTORY:,  The patient is a 25-year-old gentleman who was seen in the emergency room at Children's Hospital today.  He brought his 3-month-old daughter in for evaluation but also wanted to be evaluated himself because he has had "rib cage pain" for the last few days.  He denies any history of trauma.  He does have increased pain with laughing.  Per the patient, he also claims to have an elevated temperature yesterday of 101.  Apparently, the patient did go to the emergency room at ABCD yesterday, but due to the long wait, he left without actually being evaluated and then thought that he might be seen today when he came to Children's.,PAST MEDICAL HISTORY: , The patient has a medical history significant for "Staphylococcus infection" that was being treated with antibiotics for 10 days.,CURRENT MEDICATIONS: , He states that he is currently taking no medications.,ALLERGIES:  ,He is not allergic to any medication.,PAST SURGICAL HISTORY: , He denies any past surgical history.,SOCIAL HISTORY: , The patient apparently has a history of methamphetamine use and cocaine use approximately 1 year ago.  He also has a history of marijuana used approximately 1 year ago.  He currently states that he is in a rehab program.,FAMILY HISTORY:,  Unknown by the patient.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature is 99.9, blood pressure is 108/65, pulse of 84, respirations are 16.,GENERAL:  He is alert and appeared to be in no acute distress.  He had normal hydration.,HEENT:  His pupils were equal, round, reactive.  Extraocular muscles intact.  He had no erythema or exudate noted in his posterior oropharynx.,NECK:  Supple with full range of motion.  No lymphadenopathy noted.,RESPIRATORY:  He had equal breath sounds bilaterally with no wheezes, rales, or rhonchi and no labored breathing; however, he did occasionally have pain with deep inspiration at the right side of his chest.,CARDIOVASCULAR:  Regular rate and rhythm.  Positive S1, S2.  No murmurs, rubs, or gallops noted.,GI:  Nontender, nondistended with normoactive bowel sounds.  No masses noted.,SKIN:  Appeared normal except on the left anterior tibial area where the patient had a healing skin lesion.  There were no vesicles, erythema or induration noted.,MUSCULOSKELETAL:  Nontender with normal range of motion.,NEURO/PSYCHE:  The patient was alert and oriented x3 with nonfocal neurological exam.,ASSESSMENT: , This is a 25-year-old male with nonspecific right-sided chest/abdominal pain from an unknown etiology.,PLAN: , Due to the fact that this patient is an adult male, we will transfer him to XYZ Medical Center for further evaluation.  I have spoken with XYZ Medical Center Dr. X who has accepted the patient for transfer.  He was advised that the patient will be coming in a private vehicle due to fact that he is completely stable and appears to be in no acute distress.  Dr. X was happy to accept the transfer and indicated that the patient should come to the emergency room area with the transport paperwork.  The plan was explained in detail to the patient who stated that he understood and would comply.  The appropriate paperwork was created and one copy was given to the patient.,CONDITION ON DISCHARGE: , At the time of discharge, he was stable, vital signs stable, in no acute distress.
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DESCRIPTION: This is a 25-year-old male with nonspecific right-sided chest/abdominal pain from an unknown etiology.

The situation involves a 25-year-old male with nonspecific right-sided chest pain and an elevated temperature, seeking evaluation at a children's hospital. He has a history of substance use and a recent bacterial infection, but his current condition is stable, as indicated by normal vital signs and no acute distress. The decision to transfer him to another medical facility in a private vehicle further emphasizes the low immediacy of risk. While rib pain and elevated temperature could have various underlying causes, the context suggests the situation is managed without immediate threat to life, thereby limiting its severity.


Medical Specialty: General Medicine
Sample Name: Anemia - Consult

DIAGNOSIS:,  Refractory anemia that is transfusion dependent.,CHIEF COMPLAINT: , I needed a blood transfusion.,HISTORY: , The patient is a 78-year-old gentleman with no substantial past medical history except for diabetes.  He denies any comorbid complications of the diabetes including kidney disease, heart disease, stroke, vision loss, or neuropathy.  At this time, he has been admitted for anemia with hemoglobin of 7.1 and requiring transfusion.  He reports that he has no signs or symptom of bleeding and had a blood transfusion approximately two months ago and actually several weeks before that blood transfusion, he had a transfusion for anemia.  He has been placed on B12, oral iron, and Procrit.  At this time, we are asked to evaluate him for further causes and treatment for his anemia.  He denies any constitutional complaints except for fatigue, malaise, and some dyspnea.  He has no adenopathy that he reports.  No fevers, night sweats, bone pain, rash, arthralgias, or myalgias.,PAST MEDICAL HISTORY:  ,Diabetes.,PAST SURGICAL HISTORY:,  Hernia repair.,ALLERGIES: , He has no allergies.,MEDICATIONS: , Listed in the chart and include Coumadin, Lasix, metformin, folic acid, diltiazem, B12, Prevacid, and Feosol.,SOCIAL HISTORY: , He is a tobacco user.  He does not drink.  He lives alone, but has family and social support to look on him.,FAMILY HISTORY:,  Negative for blood or cancer disorders according to the patient.,PHYSICAL EXAMINATION:,GENERAL:  He is an elderly gentleman in no acute distress.  He is sitting up in bed eating his breakfast.  He is alert and oriented and answering questions appropriately.,VITAL SIGNS:  Blood pressure of 110/60, pulse of 99, respiratory rate of 14, and temperature of 97.4.  He is 69 inches tall and weighs 174 pounds.,HEENT:  Sclerae show mild arcus senilis in the right.  Left is clear.  Pupils are equally round and reactive to light.  Extraocular movements are intact.  Oropharynx is clear.,NECK:  Supple.  Trachea is midline.  No jugular venous pressure distention is noted.  No adenopathy in the cervical, supraclavicular, or axillary areas.,CHEST:  Clear.,HEART:  Regular rate and rhythm.,ABDOMEN:  Soft and nontender.  There may be some fullness in the left upper quadrant, although I do not appreciate a true spleen with inspiration.,EXTREMITIES:  No clubbing, but there is some edema, but no cyanosis.,NEUROLOGIC:  Noncontributory.,DERMATOLOGIC:  Noncontributory.,CARDIOVASCULAR:  Noncontributory.,IMPRESSION: , At this time is refractory anemia, which is transfusion dependent.  He is on B12, iron, folic acid, and Procrit.  There are no sign or symptom of blood loss and a recent esophagogastroduodenoscopy, which was negative.  His creatinine was 1.  My impression at this time is that he probably has an underlying myelodysplastic syndrome or bone marrow failure.  His creatinine on this hospitalization was up slightly to 1.6 and this may contribute to his anemia.,RECOMMENDATIONS:  ,At this time, my recommendation for the patient is that he undergoes further serologic evaluation with reticulocyte count, serum protein, and electrophoresis, LDH, B12, folate, erythropoietin level, and he should undergo a bone marrow aspiration and biopsy.  I have discussed the procedure in detail which the patient.  I have discussed the risks, benefits, and successes of that treatment and usefulness of the bone marrow and predicting his cause of refractory anemia and further therapeutic interventions, which might be beneficial to him.  He is willing to proceed with the studies I have described to him.  We will order an ultrasound of his abdomen because of the possible fullness of the spleen, and I will probably see him in follow up after this hospitalization.,As always, we greatly appreciate being able to participate in the care of your patient.  We appreciate the consultation of the patient.
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DESCRIPTION: Refractory anemia that is transfusion dependent.  At this time, he has been admitted for anemia with hemoglobin of 7.1 and requiring transfusion.

The situation involves a 78-year-old patient with refractory anemia requiring regular blood transfusions. This condition can potentially indicate serious underlying issues such as myelodysplastic syndrome or bone marrow failure, which can significantly affect the patient's health. The patient's dependency on transfusions and the need for further diagnostic tests highlight the importance of accurate diagnosis and management to prevent complications. While the current medical condition requires attention and further investigation, the situation is not immediately life-threatening, but it definitely demands careful management to prevent deterioration.


Medical Specialty: Orthopedic
Sample Name: Scarf Bunionectomy

PREOPERATIVE DIAGNOSIS: , Hallux abductovalgus deformity with bunion of the left foot.,POSTOPERATIVE DIAGNOSIS: , Hallux abductovalgus deformity with bunion of the left foot.,PROCEDURE PERFORMED: , Scarf bunionectomy procedure of the first metatarsal of the left foot.,ANESTHESIA:,  IV sedation with local.,HISTORY: , This patient is a 55-year-old female who presents to ABCD preoperative holding area after keeping herself n.p.o., since mid night for surgery for her painful left bunion.  The patient has had increasing pain over time and is having difficulty ambulating and wearing shoes.  The patient has failed to conservative treatment and desires surgical correction at this time.  Risks versus benefits of the procedure have been explained in detail by Dr. X, and consent is available on the chart for review.,PROCEDURE IN DETAIL:,  After an IV established by the Department of Anesthesia, the patient was given preoperatively 600 mg of clindamycin intravenously.  The patient was then taken to the Operating Suite via cart and was placed on the operating table in a supine position and a safety strap was placed across her waist for protection.  Next, a pneumatic ankle tourniquet was applied over her left ankle with copious amounts of Webril for the patient's protection.  After adequate IV sedation was applied, the patient was given a local injection consisting of 17 cc of 4.5 cc 1% lidocaine plain, 4.5 cc of 0.5% Marcaine plain, and 1.0 cc of Solu-Medrol mixture in the standard Mayo block to the left foot.  The foot was then prepped and draped in the usual sterile orthopedic fashion.  The foot was then elevated, the Esmarch was applied and the tourniquet was inflated to 250 mmHg.  The foot was then lowered to the operating field.,A sterile stockinet was reflected and the attention was directed to the first metatarsophalangeal joint of the left foot.  After sufficient anesthesia, using a #10 blade a linear incision was made approximately 5 to 6 cm in length over the first metatarsophalangeal joint dorsally, just near to the extensor hallucis longus tendon.  Then using a fresh #15 blade, this incision was deepened through the skin into the subcutaneous layer after all small traversing veins were ligated and cauterized with electrocautery.  A neurovascular bundle was identified and reflected medially.  Laterally the extensor hallucis longus tendon was identified and protected with retraction as well.  Care was then taken to undermine the medial and lateral margins of the first metatarsophalangeal joint carefully.  The first metatarsophalangeal joint capsule was then identified and using a #15 blade, a linear incision made down to the bone through the joint capsule.  The periosteum was reflected and elevated off of its bone and the metatarsal head as well as the base of the proximal phalanx to a small degree.  Noted was a large hypertrophic bone spur on the dorsal medial aspect of the first metatarsal head as well as some small osteophytes along the medial portion of the proximal phalanx.  Care was then taken to reflect and dissect the periosteum off of the shaft of the first metatarsal proximally into the proximal portion of the metatarsal close to the first metatarsocuneiform joint.  The bone cortex was noted to be intact and in good condition.  Following this, using a sagittal saw with a #138 blade, the attention was directed to the medial hypertrophic bone of the first metatarsal head.  In the sagittal plane with the blade angulated from dorsolateral to proximal medial, the medial eminence of bone was resected.  Plantarly it was noted that the tibial sesamoid groove was intact and the sesamoid apparatus was intact as well.  Following this bone cut, 0.45 K-wire was inserted from medial to lateral through the medial portion of the first metatarsal head directed in the dorsal third of the metatarsal head.  Then using the Reese osteotomy guide, the guide was directed from the distal portion of the metatarsal head proximally to the proximal portion of the first metatarsal.  A second 0.45 K-wire was inserted proximally as well.  Following this, using the sagittal saw with the #138 blade a transverse linear osteotomy cut was made through the first metatarsal from medial to lateral.  After reaching the distal as well as the proximal portions of the bone and ensuring that cortex was cut on both the medial as well as lateral side, the Reese osteotomy guide was removed and the dorsal and plantar incision cuts were made.  This began with the dorsal distal cut, which extended from medial to lateral with the dorsal portion of the blade angled proximally about five degrees through the dorsal third of the distal first metatarsal.  Following this, attention was directed proximally and an incision osteotomy cut through the bone was made, directed medially to laterally with the inferior portion of the blade angled distally to transect the cortex of the bone.  Following this, the distal portion of the osteotomy cut was freely movable and was able to be translocated medially.  The head was then slit medially several millimeters until it was noted to be in good position and no chopping was present in the medullary canal of the bone.  Following this, the bone was stabilized using a 0.45 K-wire distally as well as proximally directed from dorsal to planar direction.  Next using the normal AO manner, the distal cortex was drilled from dorsal to plantar with a 2.0 mm drill bit and then over drilled proximally with the cortex using a 2.7 mm drill bit.  The proximal cortex was then _________ and then the drill hole was measured and it was determined to be 18 mm in length from dorsal to plantar cortex.  Then using 2.7 mm tap, the thread holes were placed and using an 18 x 2.7 mm screw ___________ was achieved and good apposition of the bone and tightness were achieved.  Intramedullary sludge was noted to exit from the osteotomy cut.  Following this, attention was directed proximally and the 0.45 K-wire was removed and the holes were predrilled using a 2.0 mm screw then over-drilled using 2.7 mm screw and counter sucked.  Following this, the holes were measured, found to 20 mm in length and the drill hole was tapped using a 2.7 mm tap.  Following this, a 20 mm full threaded screw was inserted and tightened.  Good intramedullary sludge was noted and compression was achieved.  Attention was then directed to the distal screw where it was once again tightened and found to be in good position with good bite.  Following this, range of motion was performed on the first metatarsophalangeal joint and some lateral deviation of the hallux was noted.  Based on this, a lateral release was performed.  The extensor hallucis longus tendon was identified and was transected medially and a linear incision was placed down using a #15 blade into the first interspace.  The incision was then deepened with sharp and blunt dissection and using a curved hemostat, the transverse as well as the oblique fibers of the abductor hallucis tendon were identified and transected.  Care was taken to perform lateral release around the fibular sesamoid through these suspensory ligaments as well as the transverse metatarsal ligament and the collateral ligament.  Upon completion of this, the hallux was noted to be in a rectus position with good alignment.  The area was then flushed and irrigated with copious amounts of sterile saline.  After this, attention was directed back to the medial capsule and a medial capsulorrhaphy was performed and the capsule was closed using #3-0 Vicryl suture.  Subcutaneous tissues were closed using #3-0 and #4-0 Vicryl sutures to close in layers.  The skin was then reapproximated and closed using #5-0 Monocryl suture.  Following this, the incisions were dressed and bandaged in the normal manner using Owen silk, 4x4s, Kling, and Kerlix as well as Coban dressing.  The tourniquet was then dropped with a total tourniquet time of 99 minutes at 250 mmHg.  The patient followed the procedure and the anesthesia well and vascular status was intact as noted by immediate hyperemia to digits one through five of the left foot.  The patient was then transferred back to the cart and escorted on the cart to the Postanesthesia Care Unit.  Following this, the patient was given prescription for Vicoprofen total #20 to be taken one every six hours as necessary for moderate to severe pain.  The patient was also given prescription for clindamycin to be taken 300 mg four times a day.  The patient was given surgical shoe and was placed in a posterior sling.  The patient was given crutches and instructed to use them for ambulation.  The patient was instructed to keep her foot iced and elevated and to remain nonweightbearing over the weekend.  The patient will follow up with Dr. X on Tuesday morning at 11'o clock in his Livonia office.  The patient was concerned about any possible allergic reaction to medication and was placed on codeine and antibiotics due to that.  The patient has Dr. X's pager and will contact him over this weekend if she has any problems or complaints or return to Emergency Department if any difficulty should arise.  X-rays were taken and the patient was discharged home upon completion of this.
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DESCRIPTION: Scarf bunionectomy procedure of the first metatarsal of the left foot.  Hallux abductovalgus deformity with bunion of the left foot.

orthopedic, hallux abductovalgus deformity, scarf bunionectomy, metatarsal, bunion, hallux abductovalgus, metatarsophalangeal joint, dorsally, foot, bone, abductovalgus

The situation described involves a surgical procedure known as a Scarf bunionectomy, typically performed to correct a bunion which causes pain and difficulty in walking. While surgery always carries risks like infection or complications from anesthesia, this procedure is fairly common and routine in the field of orthopedic surgery. The patient has been properly informed about the risks and benefits, anesthetized, and post-operative care instructions have been given. Furthermore, the patient has a clear follow-up plan and options for emergency contacts. Thus, this does not indicate an extremely high-stakes scenario in the medical context, but rather a standard surgical procedure with manageable risks and precautions in place.


Medical Specialty: General Medicine
Sample Name: Viral Syndrome - ER Visit

SUBJECTIVE:  ,This 68-year-old man presents to the emergency department for three days of cough, claims that he has brought up some green and grayish sputum.  He says he does not feel short of breath.  He denies any fever or chills.,REVIEW OF SYSTEMS:,HEENT:  Denies any severe headache or sore throat.,CHEST:  No true pain.,GI:  No nausea, vomiting, or diarrhea.,PAST HISTORY:,  He states that he is on Coumadin because he had a cardioversion done two months ago for atrial fibrillation.  He also lists some other medications.  I do have his medications list.  He is on Pacerone, Zaroxolyn, albuterol inhaler, Neurontin, Lasix, and several other medicines.  Those are the predominant medicines.  He is not a diabetic.  The past history otherwise, he has had smoking history, but he quit several years ago and denies any COPD or emphysema.  No one else in the family is sick.,PHYSICAL EXAMINATION:,GENERAL:  The patient appears comfortable.  He did not appear to be in any respiratory distress.  He was alert.  I heard him cough once during the entire encounter.  He did not bring up any sputum at that time.,VITAL SIGNS:  His temperature is 98, pulse 71, respiratory rate 18, blood pressure 122/57, and pulse ox is 95% on room air.,HEENT:  Throat was normal.,RESPIRATORY:  He was breathing normally.  There was clear and equal breath sounds.  He was speaking in full sentences.  There was no accessory muscle use.,HEART:  Sounded regular.,SKIN:  Normal color, warm and dry.,NEUROLOGIC:  Neurologically he was alert.,IMPRESSION: , Viral syndrome, which we have been seeing in many cases throughout the week.  The patient asked me about antibiotics and I did not see a need to do this since he did not appear to have an infection other than viral given his normal temperature, normal pulse, normal respiratory rate, and near normal oxygen.  The patient being on Coumadin I explained to him that unless there was a solid reason to put him on antibiotics, he would be advised not to do so because antibiotics can alter the gut floor causing the INR to increase while on Coumadin which may cause serious bleeding.  The patient understands this.  I then asked him if the cough was annoying him, he said it was.  I offered him a cough syrup, which he agreed to take.  The patient was then discharged with Tussionex Pennkinetic a hydrocodone time-release cough syrup.  I told to check in three days, if the symptoms were not getting better.  The patient appeared to be content with this treatment and was discharged in approximately 30 to 45 minutes later.  His wife calls me very angry that I did not give him antibiotics.  I explained her exactly what I explained to him that they were not indicative at this time, and she became very upset saying that they came there specifically for antibiotics and I explained again that antibiotics are not indicated for viral infection and that I did not think he had a bacterial infection.,DIAGNOSIS: , Viral respiratory illness.
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DESCRIPTION: This 68-year-old man presents to the emergency department for three days of cough, claims that he has brought up some green and grayish sputum.  He says he does not feel short of breath.  He denies any fever or chills.

general medicine, sputum, short of breath, fever, chills, copd, emphysema, viral respiratory illness, green and grayish sputum, viral syndrome, respiratory rate, cough syrup, cough, antibiotics, inhaler,

The situation involves a medical decision-making process which could impact the patient's health. However, the condition diagnosed is a viral infection, which generally does not require antibiotics. The patient's vital signs are stable, and he is not in respiratory distress, indicating low immediate risk. The potential risk arises from the use of Coumadin, which could interact with unnecessary antibiotics to increase bleeding risk. The stakes are heightened by the patient's wife's insistence on antibiotics, requiring careful communication and education. While not immediately life-threatening, failure to carefully manage the treatment and educate the family could lead to complications, justifying a moderate stake level.


Medical Specialty: Gastroenterology
Sample Name: Ischial Ulcer Debridement

PREOPERATIVE DIAGNOSES: , Nonhealing decubitus ulcer, left ischial region? Osteomyelitis, paraplegia, and history of spina bifida.,POSTOPERATIVE DIAGNOSES: , Nonhealing decubitus ulcer, left ischial region? Osteomyelitis, paraplegia, and history of spina bifida.,PROCEDURE PERFORMED:  ,Debridement left ischial ulcer.,ANESTHESIA: ,Local MAC.,INDICATIONS:,  This is a 27-year-old white male patient, with a history of spina bifida who underwent spinal surgery about two years ago and subsequently he has been paraplegic.  The patient has a nonhealing decubitus ulcer in the left ischial region, which is quite deep.  It appears to be right down to the bone.  MRI shows findings suggestive of osteomyelitis.  The patient is being brought to operating room for debridement of this ulcer.  Procedure, indication, and risks were explained to the patient.  Consent obtained.,PROCEDURE IN DETAIL: ,The patient was put in right lateral position and left buttock and ischial region was prepped and draped.  Examination at this time showed fair amount of chronic granulation tissue and scarred tissue circumferentially as well as the base of this decubitus ulcer.  This was sharply excised until bleeding and healthy tissue was obtained circumferentially as well as the base.  The ulcer does not appear to be going into the bone itself as there was a covering on the bone, which appears to be quite healthy, normal and bone itself appeared solid.,I did not rongeur the bone.  The deeper portion of the excised tissue was also sent for tissue cultures.  Hemostasis was achieved with cautery and the wound was irrigated with sterile saline solution and then packed with medicated Kerlix.  Sterile dressing was applied.  The patient transferred to recovery room in stable condition.
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DESCRIPTION: Debridement left ischial ulcer.

Debridement left ischial ulcer.

gastroenterology, debridement, ischial ulcer, ischial region, osteomyelitis, paraplegia, spina bifida, decubitus ulcer

The case involves a medical procedure for a nonhealing decubitus ulcer in a paraplegic patient with a history of serious conditions like spina bifida and potential osteomyelitis. While the condition poses a significant risk, the procedure is a debridement, which is generally routine in managing infected or nonhealing wounds. Although it involves potential complications due to the patient's paraplegia, history, and suspected bone infection, it's not the most critical of surgical procedures. Balancing the severity of underlying conditions and the nature of the procedure suggests moderate stakes.


Medical Specialty: Dentistry
Sample Name: ORIF - Mandible Fracture

PREOPERATIVE DIAGNOSIS:,  Open left angle comminuted angle of mandible, 802.35, and open symphysis of mandible, 802.36.,POSTOPERATIVE DIAGNOSIS:,  Open left angle comminuted angle of mandible, 802.35, and open symphysis of mandible, 802.36.,PROCEDURE:,  Open reduction, internal fixation (ORIF) of bilateral mandible fractures with multiple approaches, CPT code 21470, and surgical extraction of teeth #17, CPT code 41899.,ANESTHESIA: , General anesthesia via nasal endotracheal intubation.,FLUIDS: , 1800 mL of LR.,ESTIMATED BLOOD LOSS: , 150 mL.,HARDWARE:  ,A 2.3 titanium locking reconstruction plate from Leibinger on the symphysis and a 2.0 reconstruction plate on the left angle.,SPECIMEN: , None.,COMPLICATIONS: , None.,CONDITION: , The patient was extubated to the PACU, breathing spontaneously in excellent good condition.,INDICATIONS FOR THE PROCEDURE: , The patient is a 55-year-old male that he is 12 hour status post interpersonal violence in which he sustained bilateral mandible fractures and positive loss of consciousness.  He reported to the Hospital the day after his altercation complaining of mall occlusion and sore left shoulder.  He was worked up by the emergency department.  His head CT was cleared and his left shoulder was clear of any fractures or soft tissue damage.  Oral maxillary facial surgery was consulted to manage the mandible fracture.  After review of the CT and examination it was determined that the patient would benefit from open reduction, internal fixation of bilateral mandible fractures.  Risks, benefits, and alternative to treatment were thoroughly discussed with the patient and consent was obtained.,DESCRIPTION OF PROCEDURE:, The patient was brought to the operating room #2 at Hospital.  He was laid in supine position on the operating room table.  ASA monitors were attached and stated general anesthesia was induced with IV anesthetic and maintained with nasal endotracheal intubation and inflation anesthetics.,The patient was prepped and draped in the usual oral maxillofacial surgery fashion.  The surgeon approached the operating room table in a sterile fashion.  Approximately 10 mL of 1% lidocaine with 1:100,000 epinephrine was injected into oral vestibule in a nerve block fashion.  Erich arch bars were adapted to the maxilla and mandible, secured in the posterior teeth with 24-gauge surgical steel wire and 26-gauge surgical steel wire in the anterior.  This was done from second molar to second molar on both the maxilla and the mandible secondary to the patient missing multiple teeth.  The patient was manipulated up into maximum intercuspation.  He has a malocclusion with severe bruxism and so wear facets were lined up.  This was secured with 26-gauge surgical steel wire.  Attention was then directed to the symphysis extraorally.  Approximately 5 mL of 1% lidocaine with epinephrine was injected into the area of incision which paralleled the inferior border of the mandible 2 cm below the inferior border of the mandible.,After waiting appropriate time for local anesthesia using a 15 blade, a skin and platysma incision was made.  Then using a series of blunt and sharp dissections, the dissection was carried to the inferior border of the mandible.  The periosteum was incised and reflected with the periosteal elevator.  The fracture was noted and it was displaced.  Manipulation of the segments and checking with the occlusion intraorally, the fracture was aligned.  This was secured with 7-hole 2.3 titanium locking reconstruction plate with bicortical screws.  The wound was then packed with moist Ray-Tec and attention was directed intraorally to the left angle fracture.  Approximately 5 mL of 1% lidocaine with 1:100,000 epinephrine was injected into the left vestibule.  After waiting appropriate time for local anesthesia to take effect, using Bovie electrocautery, a sagittal split incision was made and the fracture was identified.  It was noted that the fracture went through tooth #17 and this needed to be extracted.  Taking a round bur, a buckle trough was made and the tooth was elevated and removed both distal and mesial roots.  The fracture was then reduced and lateral superior border plate 2-0 4 whole with monocortical screws was placed.  The fracture was noted to be well reduced.  The wound was then irrigated with copious amount of sterile water.  The patient was released for excellent intercuspation.  He was then manipulated up into the occlusion easily.  Wound was then closed with running 3-0 chromic gut suture.  Attention was then directed extraorally.  This was irrigated with copious amount of sterile water and closed in a layer fashion with 3-0 Vicryl, 4-0 Vicryl, and 5-0 Prolene on skin.  Attention was then again directed into the mouth.  The throat pack was removed and orogastric tube was placed and stomach content was evacuated.  The patient was then manipulated back up to maximum intercuspation and secured with interdental elastics and a pressure dressing was applied to the extraoral incisions.  At this point, the procedure was then determined to be over.,The patient was extubated and breathing spontaneously, transported to the PACU in excellent condition.
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DESCRIPTION: Open left angle comminuted angle of mandible, 802.35, and open symphysis of mandible, 802.36.  Open reduction, internal fixation (ORIF) of bilateral mandible fractures with multiple approaches, CPT code 21470, and surgical extraction of teeth #17, CPT code 41899.

dentistry, mandible, endotracheal, leibinger, pacu, oral maxillary facial surgery, maxillofacial, buckle, round bur, lidocaine with epinephrine, surgical steel wire, bilateral mandible fractures, mandible fracture, orif, symphysis, fracture,

The situation involves a complex maxillofacial surgical procedure to repair bilateral mandible fractures following physical trauma. This type of surgery carries significant risks, including complications related to general anesthesia, potential for infection, and the need for precise surgical intervention to ensure proper alignment and healing. The procedure's success is crucial for restoring function and preventing long-term complications. However, as described, there were no intraoperative complications, and the patient was extubated in excellent condition. While the stakes are high due to the nature of the surgery and potential implications for the patient's health and quality of life, the immediate outcome has been positive.


Medical Specialty: General Medicine
Sample Name: Gen Med Consult - 13

SUBJECTIVE:,  The patient is a 76-year-old white female who presents to the clinic today originally for hypertension and a med check.  She has a history of hypertension, osteoarthritis, osteoporosis, hypothyroidism, allergic rhinitis and kidney stones.  Since her last visit she has been followed by Dr. Kumar.  Those issues are stable.  She has had no fever or chills, cough, congestion, nausea, vomiting, chest pain, chest pressure.,PAST MEDICAL HISTORY:,  She has an intolerance to Prevacid.,CURRENT MEDICATIONS:,  Evista 60 daily, Levothroid 0.05 mg daily, Claritin 10 daily, Celebrex 200 daily, HCTZ 25 daily and amitriptyline p.r.n.,PAST SURGICAL HISTORY:,  Bilateral mastectomies, tonsillectomy, EGD, flex sig in 2001 and a heart cath.,FAMILY HISTORY: , Father passed away at 81; mother of multiple myeloma at 83.,SOCIAL HISTORY:,  She is married.  A 76-year-old who used to smoke a pack a day and quit in 1985.  She is retired.,REVIEW OF SYSTEMS:,  Essentially negative in HEENT, chest, cardiovascular, GI, GU, musculoskeletal, or neurologic.,OBJECTIVE:,  Temperature is 97.5 degrees.  Blood pressure is 168/70.  Pulse is 88.  Weight is 129 pounds.,GENERAL:  She is an elderly 76-year-old in no acute distress.,HEENT:  Atraumatic.  Extraocular muscles were intact.  Pupils equal, round and reactive to light and accommodation.  Tympanic membranes are clear, dry and intact.  Sinuses and throat are clear.  Neck is soft, supple.  No meningeal signs are present.  No thyromegaly is present.,CHEST:  Clear to auscultation.,CARDIOVASCULAR:  Regular rate and rhythm without murmur.,ABDOMEN:  Soft, nontender.  Bowel sounds are positive.  No organomegaly or peritoneal signs are present.,EXTREMITIES:  Moving all extremities.  Peripheral pulses are normal.  No edema is present.,NEUROLOGIC:  Alert and oriented.  Cranial nerves II-XII grossly intact.  Strength 5+/5 globally.  Reflexes 2+/IV globally.  Romberg is negative.  There is no numbness, tingling, weakness or other neurologic deficit present.,BREASTS:  Surgically absent but there are no lumps, lesions, masses, discharge or adenopathy present.,BACK:  Straight.,SKIN:  Clear.,GENITALIA:  Deferred as she has been followed by Dr. XYZ many times this year.  She does have a history of some elevated cholesterol.,ASSESSMENT:,1.  Hypertension, suboptimal control.,2.  Hypothyroidism.,3.  Arthritis.,4.  Allergic rhinitis.,5.  History of kidney stones.,6.  Osteoporosis.,PLAN:,1.  CBC, complete metabolic profile, UA for hypertension.,2.  Chest x-ray for history of breast cancer.,3.  DEXA scan, full body for osteoporosis.,4.  Flex is up to date.,5.  Pneumovax has been given in the last five years.,6.  Lipid profile for elevated cholesterol.,7.  Refill meds.,8.  Follow up every three to six months for blood pressure check or sooner p.r.n. problems.
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DESCRIPTION: Consult for hypertension and a med check.  History of osteoarthritis, osteoporosis, hypothyroidism, allergic rhinitis and kidney stones.

The situation involves a routine medical consultation for an elderly patient with multiple chronic conditions, including hypertension that is suboptimally controlled, but there are no signs of acute distress or immediate life-threatening complications. The objective findings and assessment indicate stability in the patient's conditions and a planned, systematic approach to monitoring and management. This does not constitute a high-stakes medical emergency as the primary focus is ongoing management of chronic conditions with scheduled follow-ups.


Medical Specialty: Gastroenterology
Sample Name: Small Bowel Obstruction

CHIEF COMPLAINT:,  Patient AF is a 50-year-old hepatitis C positive African-American man presenting with a 2-day history of abdominal pain and distention with nausea and vomiting.,HISTORY OF PRESENT ILLNESS: , AF's symptoms began 2 days ago, and he has not passed gas or had any bowel movements.  He has not eaten anything, and has vomited 8 times.  AF reports 10/10 pain in the LLQ.,PAST MEDICAL HISTORY:,  AF's past medical history is significant for an abdominal injury during the Vietnam War which required surgery, and multiple episodes of small bowel obstruction and abdominal pain.  Other elements of his history include alcoholism, cocaine abuse, alcoholic hepatitis, hepatitis C positive, acute pancreatitis, chronic pancreatitis, appendicitis, liver hematoma/contusion, Hodgkin's Disease, constipation, diarrhea, paralytic ileus, anemia, multiple blood transfusions, chorioretinitis, pneumonia, and "crack chest pain" ,PAST SURGICAL HISTORY: , AF has had multiple abdominal surgeries, including Bill Roth Procedure Type 1 (partial gastrectomy) during Vietnam War, at least 2 exploratory laparotomies and enterolysis procedures (1993; 2000), and appendectomy,MEDICATIONS:,  None.,ALLERGIES:,  Iodine, IV contrast (anaphylaxis), and seafood/shellfish.,FAMILY HISTORY:,  Noncontributory.,SOCIAL HISTORY:,  AF was born and raised in San Francisco.  His father was an alcoholic.  He currently lives with his sister, and does not work; he collects a pension.,HEALTH-RELATED BEHAVIORS:,  AF reports that he smokes 1 to 2 cigarettes per day, and drinks 40 ounces of beer per day.,REVIEW OF SYSTEMS: , Noncontributory, except that patient reports a 6 pound weight loss since his symptoms began, and reports multiple transfusions for anemia.,PHYSICAL EXAM:,Vital Signs:  T:  37.1
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DESCRIPTION: History of abdominal pain, obstipation, and distention with nausea and vomiting - paralytic ileus and mechanical obstruction.

The situation involves a patient with a history of small bowel obstruction who is currently experiencing severe symptoms such as abdominal pain (10/10 on pain scale), vomiting, and lack of bowel movements. Given the patient's medical history, including multiple previous obstructions and surgeries, along with the presence of a serious condition like hepatitis C and prior substance abuse, this presentation is likely to require urgent medical attention. The risk of complications, such as bowel perforation or ischemia, makes this a high-stakes situation.


Medical Specialty: Discharge Summary
Sample Name: Gastrointestinal Bleed - Discharge Summary

DIAGNOSIS ON ADMISSION: , Gastrointestinal bleed.,DIAGNOSES ON DISCHARGE,1. Gastrointestinal bleed, source undetermined, but possibly due to internal hemorrhoids.,2. Atherosclerotic cardiovascular disease.,3. Hypothyroidism.,PROCEDURE:,  Colonoscopy.,FINDINGS:,  Poor prep with friable internal hemorrhoids, but no gross lesions, no source of bleed.,HOSPITAL COURSE:  ,The patient was admitted to the emergency room by Dr. X. He apparently had an NG tube placed in the emergency room with gastric aspirate revealing no blood.  Dr. Y Miller saw him in consultation and recommended a colonoscopy.  A bowel prep was done.  H&Hs were stable.  His most recent H&H was 38.6/13.2 that was this morning.  His H&H at admission was 41/14.3.  The patient had the bowel prep that revealed no significant bleeding.  His vital signs are stable.  He is continuing on his usual medications of Imdur, metoprolol, and Synthroid.  His Plavix is discontinued.  He is given IV Protonix.  I am hesitant to use Prilosec or Protonix because of his history of pancreatitis associated with Prilosec.,The patient's PT/INR was 1.03, PTT 25.8.  Chemistry panel was unremarkable.  The patient was given a regular diet after his colonoscopy today.  He tolerated it well and is being discharged home.  He will be followed closely as an outpatient.  He will continue his Pepcid 40 mg at night, Imdur, Synthroid, and metoprolol as prior to admission.  He will hold his Plavix for now.  They will call me for further dark stools and will avoid Pepto-Bismol.  They will follow up in the office on Thursday.
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DESCRIPTION: Gastrointestinal bleed, source undetermined, but possibly due to internal hemorrhoids.  Poor prep with friable internal hemorrhoids, but no gross lesions, no source of bleed.

discharge summary, atherosclerotic cardiovascular disease, colonoscopy, gross lesions, bowel prep, gastrointestinal bleed, internal hemorrhoids, hemorrhoids, gastrointestinal, prep

The situation involving a discharge summary for a patient with a gastrointestinal bleed and possibly related conditions (like internal hemorrhoids) is moderately complex and has the potential for serious health outcomes. This is because gastrointestinal bleeding can lead to significant blood loss, anemia, or other complications. Additionally, the patient has multiple conditions, such as atherosclerotic cardiovascular disease and hypothyroidism, which require careful management, and there's a need to follow up on any further symptoms that could indicate a recurring bleed. Hence, the stakes are moderate as this involves the health and well-being of the patient, but it doesn't indicate an immediate life-threatening situation since the patient is stable enough for discharge and will be closely monitored. Therefore, the stakes are neither extremely low nor extremely high.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Vaginal Hysterectomy - Laparoscopic-Assisted

PREOPERATIVE DIAGNOSES,1.  Abnormal uterine bleeding.,2.  Uterine fibroids.,POSTOPERATIVE DIAGNOSES,1.  Abnormal uterine bleeding.,2.  Uterine fibroids.,OPERATION PERFORMED: , Laparoscopic-assisted vaginal hysterectomy.,ANESTHESIA: , General endotracheal anesthesia.,DESCRIPTION OF PROCEDURE:  ,After adequate general endotracheal anesthesia, the patient was placed in dorsal lithotomy position, prepped and draped in the usual manner for a laparoscopic procedure.  A speculum was placed into the vagina.  A single tooth tenaculum was utilized to grasp the anterior lip of the uterine cervix.  The uterus was sounded to 10.5 cm.  A #10 RUMI cannula was utilized and attached for uterine manipulation.  The single-tooth tenaculum and speculum were removed from the vagina.  At this time, the infraumbilical area was injected with 0.25% Marcaine with epinephrine and infraumbilical vertical skin incision was made through which a Veress needle was inserted into the abdominal cavity.  Aspiration was negative; therefore the abdomen was insufflated with carbon dioxide.  After adequate insufflation, Veress needle was removed and an 11-mm separator trocar was introduced through the infraumbilical incision into the abdominal cavity.  Through the trocar sheath, the laparoscope was inserted and adequate visualization of the pelvic structures was noted.  At this time, the suprapubic area was injected with 0.25% Marcaine with epinephrine.  A 5-mm skin incision was made and a 5-mm trocar was introduced into the abdominal cavity for instrumentation.  Evaluation of the pelvis revealed the uterus to be slightly enlarged and irregular.  The fallopian tubes have been previously interrupted surgically.  The ovaries appeared normal bilaterally.  The cul-de-sac was clean without evidence of endometriosis, scarring or adhesions.  The ureters were noted to be deep in the pelvis.  At this time, the right cornu was grasped and the right fallopian tube, uteroovarian ligament, and round ligaments were doubly coagulated with bipolar electrocautery and transected without difficulty.  The remainder of the uterine vessels and anterior and posterior leaves of the broad ligament, as well as the cardinal ligament was coagulated and transected in a serial fashion down to level of the uterine artery.  The uterine artery was identified.  It was doubly coagulated with bipolar electrocautery and transected.  A similar procedure was carried out on the left with the left uterine cornu identified.  The left fallopian tube, uteroovarian ligament, and round ligaments were doubly coagulated with bipolar electrocautery and transected.  The remainder of the cardinal ligament, uterine vessels, anterior, and posterior sheaths of the broad ligament were coagulated and transected in a serial manner to the level of the uterine artery.  The uterine artery was identified.  It was doubly coagulated with bipolar electrocautery and transected.  The anterior leaf of the broad ligament was then dissected to the midline bilaterally, establishing a bladder flap with a combination of blunt and sharp dissection.  At this time, attention was made to the vaginal hysterectomy.  The laparoscope was removed and attention was made to the vaginal hysterectomy.  The RUMI cannula was removed and the anterior and posterior leafs of the cervix were grasped with Lahey tenaculum.  A circumferential injection with 0.25% Marcaine with epinephrine was made at the cervicovaginal portio.  A circumferential incision was then made at the cervicovaginal portio.  The anterior and posterior colpotomies were accomplished with a combination of blunt and sharp dissection without difficulty.  The right uterosacral ligament was clamped, transected, and ligated with #0 Vicryl sutures.  The left uterosacral ligament was clamped, transected, and ligated with #0 Vicryl suture.  The parametrial tissue was then clamped bilaterally, transected, and ligated with #0 Vicryl suture bilaterally.  The uterus was then removed and passed off the operative field.  Laparotomy pack was placed into the pelvis.  The pedicles were evaluated.  There was no bleeding noted; therefore, the laparotomy pack was removed.  The uterosacral ligaments were suture fixated into the vaginal cuff angles with #0 Vicryl sutures.  The vaginal cuff was then closed in a running fashion with #0 Vicryl suture.  Hemostasis was noted throughout.  At this time, the laparoscope was reinserted into the abdomen.  The abdomen was reinsufflated.  Evaluation revealed no further bleeding.  Irrigation with sterile water was performed and again no bleeding was noted.  The suprapubic trocar sheath was then removed under laparoscopic visualization.  The laparoscope was removed.  The carbon dioxide was allowed to escape from the abdomen and the infraumbilical trocar sheath was then removed.  The skin incisions were closed with #4-0 Vicryl in subcuticular fashion.  Neosporin and Band-Aid were applied for dressing and the patient was taken to the recovery room in satisfactory condition.  Estimated blood loss was approximately 100 mL.  There were no complications.  The instrument, sponge, and needle counts were correct.
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DESCRIPTION: Laparoscopic-assisted vaginal hysterectomy.  Abnormal uterine bleeding.  Uterine fibroids.

obstetrics / gynecology, abnormal uterine bleeding, laparoscopic-assisted vaginal hysterectomy, uterine fibroids, bipolar electrocautery, vaginal hysterectomy, vicryl sutures, tooth, uterine, uterosacral, laparoscope, electrocautery, hysterectomy, laparoscopic, coagulated, vaginal, ligament, transected

The described procedure is a laparoscopic-assisted vaginal hysterectomy, which is a significant surgical event, particularly in the field of obstetrics and gynecology. While it is a standard procedure for conditions like abnormal uterine bleeding and uterine fibroids, it involves general anesthesia and invasive surgery, which carries inherent risks such as bleeding, infection, and complications from anesthesia. Managing such risks is crucial, thereby making the situation moderately high-stakes. However, the procedure concluded successfully with no complications, and the stakes are routine given the medical context.


Medical Specialty: Gastroenterology
Sample Name: Esophagogastroduodenoscopy - 5

MEDICATIONS:,1.  Versed intravenously.,2.  Demerol intravenously.,DESCRIPTION OF THE PROCEDURE: , After informed consent, the patient was placed in the left lateral decubitus position and Cetacaine spray was applied to the posterior pharynx.  The patient was sedated with the above medications.  The Olympus video panendoscope was advanced under direct vision into the esophagus.  The esophagus was normal in appearance and configuration.  The gastroesophageal junction was normal.  The scope was advanced into the stomach, where the fundic pool was aspirated and the stomach was insufflated with air.  The gastric mucosa appeared normal.  The pylorus was normal.  The scope was advanced through the pylorus into the duodenal bulb, which was normal, then into the second part of the duodenum, which was normal as well.  The scope was pulled back into the stomach.  Retroflexed view showed a normal incisura, lesser curvature, cardia and fundus.  The scope was straightened out, the air removed and the scope withdrawn.  The patient tolerated the procedure well.  There were no apparent complications.,
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DESCRIPTION: Esophagogastroduodenoscopy.  The Olympus video panendoscope was advanced under direct vision into the esophagus.  The esophagus was normal in appearance and configuration.  The gastroesophageal junction was normal.

gastroenterology, duodenal bulb, gastric mucosa, olympus video, video panendoscope, gastroesophageal junction, esophagogastroduodenoscopy, gastroesophageal, pylorus, stomach, esophagus, scopeNOTE

The situation involves a routine medical procedure known as an esophagogastroduodenoscopy (EGD). This procedure is generally considered low-risk and is commonly performed to examine the lining of the esophagus, stomach, and the first part of the small intestine. The details provided indicate that the patient was sedated and the procedure was uneventful, with everything appearing normal and no complications encountered. While it is a medical procedure and inherently carries some level of risk, the fact that it's described as normal with no issues places it on the lower end of the high-stakes spectrum.


Medical Specialty: Orthopedic
Sample Name: Trigger Finger Release

PROCEDURE: , Trigger finger release.,PROCEDURE IN DETAIL: , After administering appropriate antibiotics and MAC anesthesia, the upper extremity was prepped and draped in the usual standard fashion.  The arm was exsanguinated with Esmarch, and the tourniquet inflated to 250 mmHg.,A longitudinal incision was made over the digit's A1 pulley.  Dissection was carried down to the flexor sheath with care taken to identify and protect the neurovascular bundles.  The sheath was opened under direct vision with a scalpel, and then a scissor was used to release it under direct vision from the proximal extent of the A1 pulley to just proximal to the proximal digital crease.  Meticulous hemostasis was maintained with bipolar electrocautery.,The tendons were identified and atraumatically pulled to ensure that no triggering remained.  The patient then actively moved the digit, and no triggering was noted.,After irrigating out the wound with copious amounts of sterile saline, the skin was closed with 5-0 nylon simple interrupted sutures.,The wound was dressed and the patient was sent to the recovery room in good condition, having tolerated the procedure well.
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DESCRIPTION: Trigger finger release.  A longitudinal incision was made over the digit's A1 pulley.  Dissection was carried down to the flexor sheath with care taken to identify and protect the neurovascular bundles.  The sheath was opened under direct vision with a scalpel, and then a scissor was used to release it under direct vision from the proximal extent of the A1 pulley to just proximal to the proximal digital crease.

orthopedic, a1 pulley, neurovascular bundles, trigger finger release, proximal digital, digital crease, trigger finger, trigger, finger, sheath, incision

Trigger finger release is a common surgical procedure to relieve the pain and locking associated with trigger finger, a condition where a finger gets stuck in a bent position. Although it involves surgery, it is typically a minor procedure with a high success rate and relatively low risk of serious complications. The stakes involve ensuring the patient regains full finger mobility and relieves discomfort, but they are not life-threatening or significantly complex compared to more critical surgeries.


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

Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: SOAP - Cholecystitis

SUBJECTIVE: , She is a 79-year-old female who came in with acute cholecystitis and underwent attempted laparoscopic cholecystectomy 8 days ago.  The patient has required conversion to an open procedure due to difficult anatomy.  Her postoperative course has been lengthened due to a prolonged ileus, which resolved with tetracycline and Reglan.  The patient is starting to improve, gain more strength.  She is tolerating her regular diet.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Today, her temperature is 98.4, heart rate 84, respirations 20, and BP is 140/72.,LUNGS:  Clear to auscultation.  No wheezes, rales, or rhonchi.,HEART:  Regular rhythm and rate.,ABDOMEN:  Soft, less tender.,LABORATORY DATA:,  Her white count continues to come down.  Today, it is 11.6, H&H of 8.8 and 26.4, platelets 359,000.  We have ordered type and cross for 2 units of packed red blood cells.  If it drops below 25, she will receive a transfusion.  Her electrolytes today show a glucose of 107, sodium 137, potassium 4.0, chloride 103.2, bicarbonate 29.7.  Her AST is 43, ALT is 223, her alkaline phosphatase is 214, and her bilirubin is less than 0.10.,ASSESSMENT AND PLAN:,  She had a bowel movement today and is continuing to improve.,I anticipate another 3 days in the hospital for strengthening and continued TPN and resolution of elevated white count.
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DESCRIPTION: She is a 79-year-old female who came in with acute cholecystitis and underwent attempted laparoscopic cholecystectomy 8 days ago.  The patient has required conversion to an open procedure due to difficult anatomy.  Her postoperative course has been lengthened due to a prolonged ileus, which resolved with tetracycline and Reglan.  The patient is starting to improve, gain more strength.  She is tolerating her regular diet.

soap / chart / progress notes, laparoscopic cholecystectomy, anatomy, acute cholecystitis, prolonged ileus, white count, cholecystitis

The situation involves a 79-year-old patient recovering from surgery for acute cholecystitis, complicated by a prolonged ileus, which has now resolved. The stakes are moderately high due to her age, recent surgery, and postoperative complications, although she is improving. Monitoring and potentially transfusing her if her hemoglobin drops further adds to the stakes. The medical team anticipates further hospitalization for stabilization and recovery, indicating that while the situation is being managed, it still requires careful monitoring.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Chest Tube Placement

PREOPERATIVE DIAGNOSIS: , Left pleural effusion, parapneumonic, loculated.,POSTOPERATIVE DIAGNOSIS: , Left pleural effusion, parapneumonic, loculated.,OPERATION: , Left chest tube placement.,IV SEDATION: , 5 mg of Versed total given under pulse ox monitoring, 1% lidocaine local infiltration.,PROCEDURE: , With the patient semi recumbent and supine the left anterolateral chest was prepped and draped in the usual sterile fashion.  A 1% lidocaine was liberally infiltrated into the skin, subcutaneous tissue, deep fascia and the anterior axillary line just below the level of the nipple.  The incision was made and deepened through the different layers to reach the intercostal space.  The pleura was entered on top of the underlying rib and finger digital palpation was performed.  Multiple loculations were encountered.  Break up of loculations was performed posteriorly and a chest tube was directed posteriorly.  Only a small amount of fluid was noted to come out initially.  This was sent for various studies.  Soft adhesions were encountered.  The plan was to obtain a chest x-ray and start Activase installation.
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DESCRIPTION: Left pleural effusion, parapneumonic, loculated.  Left chest tube placement.

cardiovascular / pulmonary, activase, chest tube placement, pleural effusion, chest tube, lidocaine, infiltration, parapneumonic, loculated, pleural, chest,

The scenario involves a medical procedure concerning the cardiovascular/pulmonary specialty, specifically dealing with a left pleural effusion which is parapneumonic and loculated. The placement of a chest tube is a critical procedure because it involves addressing a potentially life-threatening condition where fluid accumulates in the pleural space. It requires careful execution and monitoring, given the risks such as infection, bleeding, and potential damage to the lungs or surrounding structures. However, it is a relatively routine procedure for trained medical professionals. The stakes are significant because complications can result in serious patient outcomes, although it is not uncommon in hospital settings.


Medical Specialty: Orthopedic
Sample Name: Symes Amputation - Hallux

PREOPERATIVE DIAGNOSES:,1.  Mass, left second toe.,2.  Tumor.,3.  Left hallux bone invasion of the distal phalanx.,POSTOPERATIVE DIAGNOSES:,1.  Mass, left second toe.,2.  Tumor.,3.  Left hallux with bone invasion of the distal phalanx.,PROCEDURE PERFORMED:,1.  Excision of mass, left second toe.,2.  Distal Syme's amputation, left hallux with excisional biopsy.,HISTORY: , This 47-year-old Caucasian male presents to ABCD General Hospital with a history of tissue mass on his left foot.  The patient states that the mass has been present for approximately two weeks and has been rapidly growing in size.  The patient also has history of shave biopsy in the past.  The patient does state that he desires surgical excision at this time.,PROCEDURE IN DETAIL:,  An IV was instituted by the Department of Anesthesia in the preoperative holding area.  The patient was transported from the operating room and placed on the operating room table in the supine position with the safety belt across his lap.  Copious amount of Webril was placed around the left ankle followed by a blood pressure cuff.  After adequate sedation by the Department of Anesthesia, a total of 6 cc mixed with 1% lidocaine plain with 0.5% Marcaine plain was injected in a digital block fashion at the base of the left hallux as well as the left second toe.,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.  Care was taken with the exsanguination to perform exsanguination below the level of the digits so as not to rupture the masses.  The foot was lowered to the operating table.  The stockinet was reflected and the foot was cleansed with wet and dry sponge.  A distal Syme's incision was planned over the distal aspect of the left hallux.  The incision was performed with a #10 blade and deepened with #15 down to the level of bone.  The dorsal skin flap was removed and dissected in toto off of the distal phalanx.  There was noted to be in growth of the soft tissue mass into the dorsal cortex with erosion in the dorsal cortex and exposure of cortical bone at the distal phalanx.  The tissue was sent to Pathology where Dr. Green stated that a frozen sample would be of less use for examining for cancer.  Dr. Green did state that he felt that there was an adequate incomplete excision of the soft tissue for specimen.  At this time, a sagittal saw was then used to resect all ends of bone of the distal phalanx.  The area was inspected for any remaining suspicious tissues.  Any suspicious tissue was removed.  The area was then flushed with copious amounts of sterile saline.  The skin was then reapproximated with #4-0 nylon with a combination of simple and vertical mattress sutures.,Attention was then directed to the left second toe.  There was noted to be a dorsolateral mass over the dorsal distal aspect of the left second toe.  A linear incision was made just medial to the tissue mass.  The mass was then dissected from the overlying skin and off of the underlying capsule.  This tissue mass was hard, round, and pearly-gray in appearance.  It does not invade into any other surrounding tissues.  The area was then flushed with copious amounts of sterile saline and the skin was closed with #4-0 nylon.  Dressings consisted of Owen silk soaked in Betadine, 4x4s, Kling, Kerlix, and an Ace wrap.  The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all five digits of the left foot.  The patient tolerated the above procedure and anesthesia well without complications.  The patient was transported to PACU with vital signs stable and vascular status intact.  The patient was given postoperative pain prescription for Vicodin and instructed to follow up with Dr. Bonnani in his office as directed.  The patient will be contacted immediately pending the results of pathology.  Cultures obtained in the case were aerobic and anaerobic gram stain, Silver stain, and a CBC.
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DESCRIPTION: Excision of mass, left second toe and distal Symes amputation, left hallux with excisional biopsy.  Mass, left second toe.  Tumor.  Left hallux bone invasion of the distal phalanx.

orthopedic, distal phalanx, mass, tumor., hallux bone, phalanx, symes amputation, excisional biopsy, distal, amputation, invasion, toe, symes, incision, flushed, excision, tissue, hallux

This situation involves a surgical procedure for a patient with a rapidly growing mass and potential tumor on his left foot. The procedure performed is a distal Syme's amputation of the left hallux and excision of a mass on the left second toe, which suggests the possibility of cancer that needs to be assessed with pathology reports. The stakes are relatively high due to the invasive nature of the surgery, potential cancer diagnosis, and the permanent impact on the patient's mobility and quality of life. However, it is a planned procedure with assurances of safety and follow-up care, which somewhat mitigates the risk, but the need to determine cancer presence is crucial.


Medical Specialty: Diets and Nutritions
Sample Name: Carbohydrate Counting

SUBJECTIVE:,  This is a 62-year-old female who comes for dietary consultation for carbohydrate counting for type I diabetes.  The patient reports that she was hospitalized over the weekend for DKA.  She indicates that her blood sugar on Friday night was 187 at bedtime and that when she woke up in the morning her blood sugar was 477.  She gave herself, in smaller increments, a total of 70 extra units of her Humalog.  Ten of those units were injectable; the others were in the forms of pump.  Her blood sugar was over 600 when she went to the hospital later that day.  She is here at this consultation complaining of not feeling well still because she has a cold.  She realizes that this is likely because her immune system was so minimized in the hospital.,OBJECTIVE:,  Current insulin doses on her insulin pump are boluses set at 5 units at breakfast, 6 units at lunch and 11 units at supper.  Her basal rates have not been changed since her last visit with Charla Yassine and totaled 30.5 units per 24 hours.  A diet history was obtained.  I instructed the patient on carbohydrate counting at 1 unit of insulin for every 10 g carbohydrate ratio was recommended.  A correction dose of approximately 1 unit of insulin to bring the blood sugars down 30 mg/dl was also recommended.  The Lilly guide for meal planning was provided and reviewed.  Additional carbohydrate counting book was provided.,ASSESSMENT:,  The patient was taught an insulin-to-carbohydrate ratio of 1 unit to 10 g of carbohydrates as recommended at the previous visit two years ago, which she does not recall.  It is based on the 500 rule which suggests this ratio.  We did identify carbohydrate sources in the food supply, recognizing 15-g equivalents.  We also identified the need to dose her insulin at the time that she is eating her carbohydrate sources.  She does seem to have a pattern of fixing blood sugars later in the day after they are elevated.  We discussed the other option of trying to eat a consistent amount of carbohydrates at meals from day to day and taking a consistent amount of insulin at those meals.  With this in mind, she was recommended to follow with three servings or 45 g of carbohydrate at breakfast, three servings or 45 g of carbohydrate at lunch and four servings or 60 g of carbohydrate at dinner.  Joanne Araiza joined our consultation briefly to discuss whether her pump was working appropriately.  The patient was given an 800 number for the pump to contact should there be any question about its failure to deliver insulin appropriately.,PLAN:,  Recommend the patient use 1 unit of insulin for every 10-g carbohydrate load consumed.  Recommend the patient either use this as a carbohydrate counting tool or work harder at keeping carbohydrate content consistent at meals from day to day.  This was a one-hour consultation.  Provided my name and number should additional needs arise.
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DESCRIPTION: Dietary consultation for carbohydrate counting for type I diabetes.

diets and nutritions, insulin pump, carbohydrate load, immune system, dietary consultation, carbohydrate ratio, blood sugars, carbohydrate counting, carbohydrate, dietary, blood, counting, insulin

The situation involves a consultation for managing type I diabetes, a serious chronic condition that requires meticulous management to prevent acute and long-term complications. The patient recently experienced diabetic ketoacidosis (DKA), a serious and potentially life-threatening condition that demands careful monitoring and adjustment of dietary and insulin management strategies. The stakes are high as improper management can lead to severe health consequences, including hospitalization. Additionally, the patient is currently unwell and there is uncertainty about her insulin pump's functionality, adding complexity to her diabetes management.


Medical Specialty: Pain Management
Sample Name: Epidural Steroid Block

DIAGNOSIS: , Left sciatica.,ANESTHESIA: , Intravenous sedation,NAME OF OPERATION:,1.  Left L5-S1 transforaminal epidural steroid block with fluoroscopy.,2.  Left L4-5 transforaminal epidural steroid block with fluoroscopy.,3.  Monitored intravenous Versed sedation.,PROCEDURE: , The patient was taken to the block room.  He was placed prone on the fluoroscopy table.  He was monitored appropriately.  He was administered Versed 2 mg IV.  His O2 saturation remained greater than 90%.  His back was prepped and draped.  The C-arm was brought in.  The endplates at L5-S1 were squared off.  The C-arm was rotated to the left.  The L5 pedicle, the superior articular process of the L5-S1 facet, and the "neck of the scotty dog" were all visualized.  After adequate local anesthesia, a 22-gauge, 3-1/2-inch spinal needle was inserted using down-the-barrel-of-the-needle technique.  The needle was advanced into the posterior aspect of the foramen and then advanced anteriorly toward the 6 o'clock position on the pedicle.  No paresthesias were noted.  One-half cc of contrast was injected and spread medially around the pedicle and into the epidural space, and the L5 nerve root was visualized.  Depo-Medrol 80 mg plus 1 cc of 4% preservative-free lidocaine was injected.  The needle was flushed and removed.,I then went up to the L4-5 level, and using a similar technique, injected the patient transforaminally at the L4-5 level.  Depo-Medrol 80 mg plus 1 cc of 4% preservative-free lidocaine was injected at the L4-5 level just as at the L5-S1 level.  The patient had pain down his left leg during the injection, primarily at the L5-S1 level similar to what he normally experiences.  He was awake and alert, and taken to the recovery room in good condition.  His left leg pain was relieved.
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DESCRIPTION: Transforaminal epidural steroid block with fluoroscopy.

pain management, c-arm, epidural steroid block with fluoroscopy, sciatica, transforaminal, steroid block with fluoroscopy, epidural steroid block, depo medrol, transforaminal epidural, steroid block, fluoroscopy, epidural, intravenous, steroid,

The procedure described in the scenario is a routine medical procedure for pain management, specifically targeting sciatica through epidural steroid blocks. It involves commonplace practices such as the use of intravenous sedation and fluoroscopy to manage pain, and the patient was monitored throughout, experiencing typical pain associated with the condition. No complications or extraordinary circumstances are noted, and the patient was reported to be in good condition post-procedure. While it requires medical skill and attention to patient well-being, it is not an emergency intervention or a complex surgery with high-risk potential.


Medical Specialty: Radiology
Sample Name: MRI Brain - Wernicke aphasia

CC: ,Difficulty with speech.,HX:, This 72 y/o RHM awoke early on 8/14/95 to prepare to play golf. He felt fine. However, at 6:00AM, on 8/14/95, he began speaking abnormally. His wife described his speech as "word salad" and "complete gibberish." She immediately took him to a local hospital . Enroute, he was initially able to understand what was spoken to him. By the time he arrived at the hospital at 6:45AM, he was unable to follow commands. His speech was reportedly unintelligible the majority of the time, and some of the health care workers thought he was speaking a foreign language. There were no other symptoms or signs. He had no prior history of cerebrovascular disease. Blood pressure 130/70 and Pulse 82 upon admission to the local hospital on 8/14/95.,Evaluation at the local hospital included: 1)HCT scan revealed an old left putaminal hypodensity, but no acute changes or evidence of hemorrhage, 2) Carotid Duplex scan showed ICA stenosis of 40%, bilaterally. He was placed on heparin and transferred to UIHC on 8/16/95.,In addition, he had noted memory and word finding difficulty for 2 months prior to presentation. He had undergone a gastrectomy 16 years prior for peptic ulcer disease. His local physician found him vitamin B12 deficient and he was placed on vitamin B12 and folate supplementation 2 months prior to presentation. He and his wife felt that this resulted in improvement of his language and cognitive skills.,MEDS:, Heparin IV, Vitamin B12 injection q. week, Lopressor, Folate, MVI.,PMH:, 1)Hypothyroidism (reportedly resolved), 2) Gastrectomy, 3)Vitamin B12 deficiency.,FHX: ,Mother died of MI, age 70. Father died of prostate cancer, age 80. Bother died of CAD and prostate cancer, age 74.,SHX:, Married. 3 children who are alive and well. Semi-retired Attorney. Denied h/o tobacco/ETOH/illicit drug use.,EXAM:, BP 110/70, HR 50, RR 14, Afebrile.,MS: A&O to person and place, but not time. Oral comprehension was poor beyond the simplest of conversational phrases. Speech was fluent, but consisted largely of "word salad." When asked how he was, he replied: "abadeedleedlebadle." Repetition was defective, especially with long phrases. On rare occasions, he uttered short comments appropriately. Speech was marred by semantic and phonemic paraphasias. He named colors and described most actions well, although he described a "faucet dripping" as a "faucet drop." He called "red" "reed." Reading comprehension was better than aural comprehension. He demonstrated excellent written calculations. Spoken calculations were accurate except when the calculations became more complex. For example, he said that ten percent of 100 was equal to "1,200.",CN: Pupils 2/3 decreasing to 1/1 on exposure to light. VFFTC. There were no field cuts or evidence of visual neglect. EOM were intact. Face moved symmetrically. The rest of the CN exam was unremarkable.,MOTOR: Full strength throughout with normal muscle tone and bulk. There was no evidence of drift.,SENSORY: unremarkable.,COORD: unremarkable.,Station: unremarkable. Gait: mild difficulty with TW.,Reflexes: 2/2 in BUE. 2/2+ patellae, 1/1 Achilles. Plantar responses were flexor on the left and equivocal on the right.,Gen Exam: unremarkable.,COURSE:, Lab data on admission: Glucose 97, BUN 20, Na 134, K 4.0, Cr 1.3, Chloride 98, CO2 24, PT 11, PTT 42, WBC 12.0 (normal differential), Hgb 11.4, Hct 36%, Plt=203k. UA normal. TSH 6.0, FT4 0.88, Vit B12 876, Folate 19.1. He was admitted and continued on heparin. MRI scan, 8/16/95, revealed increased signal on T2-weighted images in Wernicke's area in the left temporal region. Transthoracic echocardiogram on 8/17/95 was unremarkable. Transesophageal echocardiogram on 8/18/95 revealed a sclerotic aortic valve and myxomatous degeneration of the anterior leaflet of the mitral valve. LAE 4.8cm, and spontaneous echo contrast in the left atrium were noted. There was no evidence of intracardiac shunt or clot. Carotid duplex scan on 8/16/95 revealed 0-15% BICA stenosis with anterograde vertebral artery flow, bilaterally. Neuropsychologic testing revealed a Wernicke's aphasia.,The impression was that the patient had had a cardioembolic stroke involving a lower-division branch of the left MCA. He was subsequently placed on warfarin. Thoughout his hospital stay he showed continued improvement of language skills and was enrolled in speech therapy following discharge, 8/21/95.,He has had no further stroke like episodes up until his last follow-up visit in 1997.
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DESCRIPTION: MRI Brain: Left Basal Ganglia, Posterior temporal lobe, and Left cerebellar (lacunar) infarctions with Wernickes Aphasia.

radiology, mri brain, difficulty with speech, left basal ganglia, posterior temporal lobe, wernicke's area, wernickes aphasia, cerebellar, infarctions, lacunar, word finding difficulty, carotid duplex scan, aphasia, wernicke's, mri, brain,

This case involves a patient who experienced sudden onset of Wernicke's aphasia, which is often indicative of a stroke. Given the impaired language function, the age of the patient, and the medical emergency response, it suggests a high-stakes medical situation because timely diagnosis and treatment can significantly affect outcomes in stroke cases. Although the patient improved and did not have further stroke episodes, the initial presentation was critical, necessitating immediate attention and intervention. The long-term management including anticoagulation therapy also adds complexity to the case.