Medical Specialty: Surgery
Sample Name: Ahmed Shunt Placement

PROCEDURE IN DETAIL:  ,While in the holding area, the patient received a peripheral IV from the nursing staff.  In addition, pilocarpine 1% was placed into the operative eye, two times, separated by 10 minutes.  The patient was wheeled to the operating suite where the anesthesia team established peripheral monitoring lines.  Through the IV, the patient received IV sedation in the form of propofol and once somnolent from this, a retrobulbar block was administrated consisting of 2% Xylocaine plain.  Approximately 3 mL were administered.  The patient then underwent a Betadine prep with respect to the face, lens, lashes, and eye.  During the draping process, care was taken to isolate the lashes.  A Vicryl traction suture was placed through the superior cornea and the eye was reflected downward to expose the superior temporal conjunctiva.  Approximately 8 to 10 mm posterior to limbus, the conjunctiva was incised and dissected forward to the limbus.  Blunt dissection was carried out in the superotemporal quadrant.  Next, a 2 x 3-mm scleral flap was outlined that was one-half scleral depth in thickness.  This flap was cut forward to clear cornea using a crescent blade.  The Ahmed shunt was then primed and placed in the superior temporal quadrant and it was sutured in place with two 8-0 nylon sutures.  The knots were trimmed.  The tube was then cut to an appropriate length to enter the anterior chamber.  The anterior chamber was then entered after a paracentesis wound had been made temporally.  A trabeculectomy was done and then the tube was threaded through the trabeculectomy site.  The tube was sutured in place with a multi-wrapped 8-0 nylon suture.  The scleral flap was then sutured in place with two 10-0 nylon sutures.  The knots were trimmed, rotated and buried.  A scleral patch was then placed of an appropriate size over the two.  It was sutured in place with interrupted 8-0 nylon sutures.  The knots were trimmed.  The overlying conjunctiva was then closed with a running 8-0 Vicryl suture with a BV needle.  The anterior chamber was filled with Viscoat to keep it deep as the eye was somewhat soft.  A good flow was established with irrigation into the anterior chamber.  Homatropine, Econopred, and Vigamox drops were placed into the eye.  A patch and shield were placed over the eye after removing the draping and the speculum.  The patient tolerated the procedure well.  He was taken to the recovery in good condition.  He will be seen in followup in the office tomorrow.
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DESCRIPTION: The Ahmed shunt was primed and placed in the superior temporal quadrant and it was sutured in place with two 8-0 nylon sutures.  The knots were trimmed.

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

The procedure described is a detailed account of a surgical operation involving the placement of an Ahmed shunt, which is typically used to manage glaucoma by helping to drain excess fluid from the eye to reduce intraocular pressure. This type of surgery is delicate and involves precise steps to ensure the patient's vision is preserved while minimizing the risk of complications such as infection or bleeding. Given the detailed nature of the surgery, the involvement of anesthesia, and the potential risks and consequences associated with surgical errors, it is considered a high-stakes procedure. However, the description notes that the patient tolerated the procedure well and is in good condition, which slightly reduces the immediate risk level post-procedure.


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

Medical Specialty: Neurology
Sample Name: Neuropsychological Evaluation - 3

REASON FOR REFERRAL:,  The patient is a 76-year-old Caucasian gentleman who works full-time as a tax attorney.  He was referred for a neuropsychological evaluation by Dr. X after a recent hospitalization for possible transient ischemic aphasia.  Two years ago, a similar prolonged confusional spell was reported as well.  A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning.,RELEVANT BACKGROUND INFORMATION: , Historical information was obtained from a review of available medical records and clinical interview with the patient.  A summary of pertinent information is presented below.  Please refer to the patient's medical chart for a more complete history.,HISTORY OF PRESENTING PROBLEM: , The patient was brought to the Hospital Emergency Department on 09/30/09 after experiencing an episode of confusion for which he has no recall the previous day.  He has no recollection of the event.  The following information is obtained from his medical record.  On 09/29/09, he reportedly went to a five-hour meeting and stated several times "I do not feel well" and looked "glazed."  He does not remember anything from midmorning until the middle of the night and when his wife came home, she found him in bed at 6 p.m., which is reportedly unusual.  She thought he was warm and had chills.  He later returned to his baseline.  He was seen by Dr. X in the hospital on 09/30/09 and reported to him at that time that he felt that he had returned entirely to baseline.  His neurological exam at that time was unremarkable aside from missing one of three items on recall for the Mini-Mental Status Examination.  Due to mild memory complaints from himself and his wife, he was referred for more extensive neuropsychological testing.  Note that reportedly when his wife found him in bed, he was shaking and feeling nauseated, somewhat clammy and kept saying that he could not remember anything and he was repeating himself, asking the same questions in an agitated way, so she brought him to the emergency room.  The patient had an episode two years ago of transient loss of memory during which he was staring blankly while sitting at his desk at work and the episode lasted approximately two hours.  He was hospitalized at Hospital at that time as well and evaluation included negative EEG, MRI showing mild atrophy, and a neurological consultation, which did not result in a specific diagnosis, but during this episode he was also reportedly nauseous.  He was also reportedly amnestic for this episode.,In 2004, he had a sense of a funny feeling in his neck and electrodes in his head and had an MRI at that time which showed some small vessel changes.,During this interview, the patient reported that other than a coworker noticing a few careless errors in his completion of some documents and his wife reporting some mild memory changes that he had not noticed any significant decline.  He thought that his memory abilities were similar to those of his peers of his same age.  When I asked about this episode, he said he had no recall of it at all and that he "felt fine the whole time."  He appeared to be somewhat questioning of the validity of reports that he was amnestic and confused at that time.  So, The patient reported some age related "memory lapses" such as going into a room and forgetting why, sometimes putting something down and forgetting where he had put it.  However, he reported that these were entirely within normal expectations and he denied any type of impairment in his ability to continue to work full-time as a tax attorney other than his wife and one coworker, he had not received any feedback from his children or friends of any problems.  He denied any missed appointments, any difficulty scheduling and maintaining appointments.  He does not have to recheck information for errors.  He is able to complete tasks in the same amount of time as he always has.  He reported that he has not made additional errors in tasks that he completed.  He said he does write everything down, but has always done things that way.  He reported that he works in a position that requires a high level of attentiveness and knowledge and that will become obvious very quickly if he was having difficulties or making mistakes.  He did report some age related changes in attention as well, although very mild and he thought these were normal and not more than he would expect for his age.  He remains completely independent in his ADLs.  He denied any difficulty with driving or maintaining any activities that he had always participated in.  He is also able to handle their finances.  He did report significant stress recently particularly in relation to his work environment.,PAST MEDICAL HISTORY:,  Includes coronary artery disease, status post CABG in 1991, radical prostate cancer, status post radical prostatectomy, nephrectomy for the same cancer, hypertension, lumbar surgery done twice previously, lumbar stenosis many years ago in the 1960s and 1970s, now followed by Dr. Y with another lumbar surgery scheduled to be done shortly after this evaluation, and hyperlipidemia.  Note that due to back pain, he had been taking Percocet daily prior to his hospitalization.,CURRENT MEDICATIONS: , Celebrex 200 mg, levothyroxine 0.025 mg, Vytorin 10/40 mg, lisinopril 10 mg, Coreg 10 mg, glucosamine with chondroitin, prostate 2.2, aspirin 81 mg, and laxative stimulant or stool softener.  Note that medical records say that he was supposed to be taking Lipitor 40 mg, but it is not clear if he was doing so and also there was no specific reason found for why he was taking the levothyroxine.,OTHER MEDICAL HISTORY: , Surgical history is significant for hernia repair in 2007 as well.  The patient reported drinking an occasional glass of wine approximately two days of the week.  He quit smoking cigarettes 25 to 30 years ago and he was diagnosed with cancer.  He denied any illicit drug use.  Please add that his prostatectomy was done in 1993 and nephrectomy in 1983 for carcinoma.  He also had right carpal tunnel surgery in 2005 and has cholelithiasis.  Upon discharge from the hospital, the patient's sleep deprived EEG was recommended.,MRI completed on 09/30/09 showed "mild cerebral and cerebellar atrophy with no significant interval change from a prior study dated June 15, 2007.  No evidence of acute intracranial processes identified.  CT scan was also unremarkable showing only mild cerebral and cerebellar atrophy.  EEG was negative.  Deferential diagnosis was transient global amnesia versus possible seizure disorder.  Note that he also reportedly has some hearing changes, but has not followed up with an evaluation for hearing aid.,FAMILY MEDICAL HISTORY:, Reportedly significant for TIAs in his mother, although the patient did not report this during our evaluation and so that she had no memory problems or dementia when she passed away of old age at the age of 85.  In addition, his father had a history of heart disease and passed away at the age of 75.  He has one sister with diabetes and thought his mom might have had diabetes as well.,SOCIAL HISTORY:,  The patient obtained a law degree from the University of Baltimore.  He did not complete his undergraduate degree from the University of Maryland because he was able to transfer his credits in order to attend law school at that time.  He reported that he did not obtain very good grades until he reached law school, at which point he graduated in the top 10 of his class and had no problem passing the Bar.  He thought that effort and motivation were important to his success in his school and he had not felt very motivated previously.  He reported that he repeated math classes "every year of school" and attended summer school every year due to that.  He has worked as a tax attorney for the past 48 years and reported having a thriving practice with clients all across the country.  He served also in the U.S.  Coast Guard between 1951 and 1953.  He has been married for the past 36 years to his wife, Linda, who is a homemaker.  They have four children and he reported having good relationship with them.  He described being very active.  He goes for dancing four to five times a week, swims daily, plays golf regularly and spends significant amounts of time socializing with friends.,PSYCHIATRIC HISTORY: , The patient denied any history of psychological or psychiatric treatment.  He reported that some stressors occasionally contribute to mildly low mood at this time, but that these are transient.,TASKS ADMINISTERED:,Clinical Interview,Adult History Questionnaire,Wechsler Test of Adult Reading (WTAR),Mini Mental Status Exam (MMSE),Cognistat Neurobehavioral Cognitive Status Examination,Repeatable Battery for the Assessment of Neuropsychological Status (RBANS; Form XX),Mattis Dementia Rating Scale, 2nd Edition (DRS-2),Neuropsychological Assessment Battery (NAB),Wechsler Adult Intelligence Scale, Third Edition (WAIS-III),Wechsler Adult Intelligence Scale, Fourth Edition (WAIS-IV),Wechsler Abbreviated Scale of Intelligence (WASI),Test of Variables of Attention (TOVA),Auditory Consonant Trigrams (ACT),Paced Auditory Serial Addition Test (PASAT),Ruff 2 & 7 Selective Attention Test,Symbol Digit Modalities Test (SDMT),Multilingual Aphasia Examination, Second Edition (MAE-II), Token Test, Sentence Repetition, Visual Naming, Controlled Oral Word Association, Spelling Test, Aural Comprehension, Reading Comprehension,Boston Naming Test, Second Edition (BNT-2),Animal Naming Test
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DESCRIPTION: Patient was referred for a neuropsychological evaluation after a recent hospitalization for possible transient ischemic aphasia.  Two years ago, a similar prolonged confusional spell was reported as well.  A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning.

The situation involves a 76-year-old tax attorney who has experienced possible transient ischemic aphasia and prolonged confusional spells, which could indicate underlying neurological issues. The evaluation is crucial for diagnosing potential cognitive disorders, such as dementia or a seizure disorder, and guiding treatment. His ability to continue his profession and maintain his independence, quality of life, and potentially his life, depend on accurate diagnosis and management. Therefore, it's a high-stakes situation due to health and significant lifestyle implications.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Podiatry
Sample Name: Diabetic Foot Care

S - ,An 83-year-old diabetic female presents today stating that she would like diabetic foot care.,O - ,On examination, the lateral aspect of her left great toenail is deeply ingrown.  Her toenails are thick and opaque.  Vibratory sensation appears to be intact.  Dorsal pedal pulses are 1/4.  There is no hair growth seen on her toes, feet or lower legs.  Her feet are warm to the touch.  All of her toenails are hypertrophic, opaque, elongated and discolored.,A - ,1.  Onychocryptosis.,
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DESCRIPTION: An 83-year-old diabetic female presents today stating that she would like diabetic foot care.

podiatry, onychocryptosis, onychomycosis, great toenail, diabetic foot care, diabetic foot, foot, toenail, ingrown, toenails, diabetic,

Diabetic foot care is a critical issue due to the potential for severe complications such as infections or ulcers, particularly in elderly patients with compromised circulation as indicated by decreased pedal pulses and thickened, opaque toenails. The presence of an ingrown toenail adds to the risk because it can lead to infection. These factors can potentially lead to more severe systemic issues if not properly managed, indicating a moderately high-stakes situation.


Medical Specialty: Gastroenterology
Sample Name: Laparoscopic Cholecystectomy & Appendectomy

PREOPERATIVE DIAGNOSIS: , Symptomatic cholelithiasis.,POSTOPERATIVE DIAGNOSIS: , Symptomatic cholelithiasis.,PROCEDURE: , Laparoscopic cholecystectomy and appendectomy (CPT 47563, 44970).,ANESTHESIA: , General endotracheal.,INDICATIONS:  ,This is an 18-year-old girl with sickle cell anemia who has had symptomatic cholelithiasis.  She requested appendectomy because of the concern of future diagnostic dilemma with pain crisis.  Laparoscopic cholecystectomy and appendectomy were recommended to her.  The procedure was explained in detail including the risks of bleeding, infection, biliary injury, retained common duct stones.  After answering her questions, she wished to proceed and gave informed consent.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room, placed supine on the operating table.  She was positively identified and the correct surgical site and procedure reviewed.  After successful administration of general endotracheal anesthesia, the skin of the abdomen was prepped with chlorhexidine solution and sterilely draped.,The infraumbilical skin was infiltrated with 0.25% bupivacaine with epinephrine and horizontal incision created.  The linea alba was grasped with a hemostat and Veress needle was placed into the peritoneal cavity and used to insufflate carbon dioxide gas to a pressure of 15 mmHg.  A 12-mm expandable disposable trocar was placed and through this a 30 degree laparoscope was used to inspect the peritoneal cavity.  Upper abdominal anatomy was normal.  Pelvic laparoscopy revealed bilaterally closed internal inguinal rings.  Additional trocars were placed under direct vision including a 5-mm reusable in the right lateral _____.  There was a 12-mm expandable disposable in the right upper quadrant and a 5-mm reusable in the subxiphoid region.  Using these, the gallbladder was grasped and retraced cephalad.  Adhesions were taken down over the cystic duct and the duct was circumferentially dissected and clipped at the gallbladder cystic duct junction.  A small ductotomy was created.  Reddick cholangiogram catheter was then placed within the duct and the balloon inflated.  Continuous fluoroscopy was used to instill contrast material.  This showed normal common bile duct which entered the duodenum without obstruction.  There was no evidence of common bile duct stones.  The cholangiogram catheter was removed.  The duct was doubly clipped and divided.  The artery was divided and cauterized.  The gallbladder was taken out of the gallbladder fossa.  It was then placed in Endocatch bag and left in the abdomen.  Attention was then paid to the appendix.  The appendix was identified and window was made in the mesoappendix at the base.  This was amputated with an Endo-GIA stapler.  The mesoappendix was divided with an Endo-GIA vascular stapler.  This was placed in another Endocatch bag.  The abdomen was then irrigated.  Hemostasis was satisfactory.  Both the appendix and gallbladder were removed and sent for pathology.  All trocars were removed.  The 12-mm port sites were closed with 2-0 PDS figure-of-eight fascial sutures.  The umbilical skin was reapproximated with interrupted 5-0 Vicryl Rapide.  The remaining skin incisions were closed with 5-0 Monocryl subcuticular suture.  The skin was cleaned.  Mastisol, Steri-Strips and band-aids were applied.  The patient was awakened, extubated in the operating room, transferred to the recovery room in stable condition.
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DESCRIPTION: Symptomatic cholelithiasis.  Laparoscopic cholecystectomy and appendectomy (CPT 47563, 44970).  The patient requested appendectomy because of the concern of future diagnostic dilemma with pain crisis.  Laparoscopic cholecystectomy and appendectomy were recommended to her.

gastroenterology, endo-gia, endocatch bag, symptomatic cholelithiasis, laparoscopic cholecystectomy, appendectomy, cholangiogram, mesoappendix, abdomen, appendix, cholelithiasis, endotracheal, laparoscopic, cholecystectomy, gallbladder, duct

The situation involves a surgical procedure on an 18-year-old patient for symptomatic cholelithiasis and potential issues related to sickle cell anemia, which introduces moderate complexity and risk due to the combination of conditions. However, the procedure is a planned and elective laparoscopic cholecystectomy and appendectomy executed with standard protocols, not an emergency, which reduces urgency but requires competency and careful management due to anesthesia and potential for complications like bleeding or infection. Given these circumstances, it is moderately high-stakes, particularly due to the specific risks related to the patient's sickle cell anemia.


Medical Specialty: Gastroenterology
Sample Name: Exploratory Laparotomy - 1

PREOPERATIVE DIAGNOSIS:,  History of perforated sigmoid diverticuli with Hartmann's procedure.,POSTOPERATIVE DIAGNOSES:  ,1.  History of perforated sigmoid diverticuli with Hartmann's procedure.,2.  Massive adhesions.,PROCEDURE PERFORMED:,1.  Exploratory laparotomy.,2.  Lysis of adhesions and removal.,3.  Reversal of Hartmann's colostomy.,4.  Flexible sigmoidoscopy.,5.  Cystoscopy with left ureteral stent.,ANESTHESIA: , General.,HISTORY: , This is a 55-year-old gentleman who had a previous perforated diverticula.  Recommendation for reversal of the colostomy was made after more than six months from the previous surgery for a sigmoid colon resection and Hartmann's colostomy.,PROCEDURE:  ,The patient was taken to the operating room placed into lithotomy position after being prepped and draped in the usual sterile fashion.  A cystoscope was introduced into the patient's urethra and to the bladder.  Immediately, no evidence of cystitis was seen and the scope was introduced superiorly, measuring the bladder and immediately a #5 French ____ was introduced within the left urethra.  The cystoscope was removed, a Foley was placed, and wide connection was placed attaching the left ureteral stent and Foley.  At this point, immediately the patient was re-prepped and draped and immediately after the ostomy was closed with a #2-0 Vicryl suture, immediately at this point, the abdominal wall was opened with a #10 blade Bard-Parker down with electrocautery for complete hemostasis through the midline.,The incision scar was cephalad due to the severe adhesions in the midline.  Once the abdomen was entered in the epigastric area, then massive lysis of adhesions was performed to separate the small bowel from the anterior abdominal wall.  Once the small bowel was completely free from the anterior abdominal wall, at this point, the ostomy was taken down with an elliptical incision with cautery and then meticulous dissection with Metzenbaum scissors and electrocautery down to the anterior abdominal wall, where a meticulous dissection was carried with Metzenbaum scissors to separate the entire ostomy from the abdominal wall.  Immediately at this point, the bowel was dropped within the abdominal cavity, and more lysis of adhesions was performed cleaning the left gutter area to mobilize the colon further down to have no tension in the anastomosis.  At this point, the rectal stump, where two previous sutures with Prolene were seen, were brought with hemostats.  The rectal stump was free in a 360 degree fashion and immediately at this point, a decision to perform the anastomosis was made.  First, a self-retaining retractor was introduced in the abdominal cavity and a bladder blade was introduced as well.  Blue towel was placed above the small bowel retracting the bowel to cephalad and at this point, immediately the rectal stump was well visualized, no evidence of bleeding was seen, and the towels were placed along the edges of the abdominal wound.  Immediately, the pursestring device was fired approximately 1 inch from the skin and on the descending colon, this was fired.  The remainder of the excess tissue was closed with Metzenbaum scissors and immediately after dilating #25 and #29 mushroom tip from the T8 Ethicon was placed within the colon and then #9-0 suture was tied.  Immediately from the anus, the dilator #25 and #29 was introduced dilating the rectum.  The #29 EEA was introduced all the way anteriorly to the staple line and this spike from the EEA was used to perforate the rectum and then the mushroom from the descending colon was attached to it.  The EEA was then fired.  Once it was fired and was removed, the pelvis was filled with fluid.  Immediately both doughnuts were ____ from the anastomosis.  A Doyen was placed in both the anastomosis.  Colonoscope was introduced.  No bubble or air was seen coming from the anastomosis.  There was no evidence of bleeding.  Pictures of the anastomosis were taken.  The scope then was removed from the patient's rectum.  Copious amount of irrigation was used within the peritoneal cavity.  Immediately at this point, all complete sponge and instrument count was performed.  First, the ostomy site was closed with interrupted figure-of-eight #0 Vicryl suture.  The peritoneum was closed with running #2-0 Vicryl suture.  Then, the midline incision was closed with a loop PDS in cephalad to caudad and caudad to cephalad tight in the middle.  Subq tissue was copiously irrigated and the staples on the skin.,The iodoform packing was placed within the old ostomy site and then the staples on the skin as well.  The patient did tolerate the procedure well and will be followed during the hospitalization.  The left ureteral stent was removed at the end of the procedure.  _____ were performed.  Lysis of adhesions were performed.  Reversal of colostomy and EEA anastomosis #29 Ethicon.
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DESCRIPTION: Exploratory laparotomy, lysis of adhesions and removal, reversal of Hartmann's colostomy, flexible sigmoidoscopy, and cystoscopy with left ureteral stent.

gastroenterology, reversal of hartmann's colostomy, flexible sigmoidoscopy, cystoscopy, ureteral stent, lysis of adhesions, exploratory laparotomy, hartmann's colostomy, abdominal wall, immediately, adhesions, colostomy, sigmoidoscopy, bowel, anastomosis, abdominal

The scenario involves a complex surgical procedure after a history of significant medical events, including a perforated colon and a previous serious surgery (Hartmann's procedure). The procedure includes an exploratory laparotomy, reversal of a colostomy, and intricate adhesion lysis. Due to the complexity of the surgery, the involvement of multiple critical organs, and the potential for complications, this is a high-stakes situation. The outcome of this surgery can significantly impact the patient's future health and quality of life.


Medical Specialty: Radiology
Sample Name: CT of Facial Wones w/o Contrast

EXAM:,  CT of the facial bones without contrast.,REASON FOR EXAM:,  Hit in nose.,COMPARISON EXAM: , Plain films of the same date.,TECHNIQUE: , Multidetector helicoaxial images were acquired in the axial plane and were reconstructed in bone and soft tissue algorithms for viewing in multiplanar format.,FINDINGS: , There is a fracture of the frontal process of the maxilla on both sides with displacement with angulation to the right and very minimal displacement of the distal fragments.  In addition, there is slight comminution of the right nasal bone without displacement.  The bony portion of the nasal septum is intact, although it is bowed to the left.  Soft tissue swelling is seen overlying the left side of the nose.  There is no nasoseptal hematoma.  Moderate mucosal thickening is seen in both maxillary sinuses.  The right maxillary sinus is hypoplastic.  Moderate mucosal thickening is seen in the left ethmoid sinus and marked mucosal thickening in the left sphenoid sinus.  The right sphenoid sinus is hypoplastic.  No abnormality of the orbits is seen.  The imaged portions of the brain are unremarkable.,IMPRESSION:,1.  Bilateral fractures of the frontal process of the maxilla and with displacement to the right.,2.  The findings were reported to Dr. Xyz of the emergency room on 04/30/07 at 1715 hours.
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DESCRIPTION: CT of the facial bones without contrast due to hit in nose.

radiology, plain films, ct, multidetector, axial plane, bone, contrast, frontal, helicoaxial, maxilla, mucosal thickening, multiplanar, nasal bone, nasoseptal hematoma, sinus, soft tissue, sphenoid, without contrast, sinus is hypoplastic, facial, mucosal, thickening

This situation involves medical imaging and diagnosis of facial fractures. While facial fractures can potentially affect important functions and require medical intervention, this case does not report life-threatening injuries or complications like severe hematomas, brain injury, or airway obstruction. The primary finding is a fracture of the maxilla with displacement but no alarming abnormalities in the brain or other critical regions. The scenario seems to be under control as findings have already been communicated to the emergency room. Given these facts, the situation is moderately important but not extremely high-stakes.


Medical Specialty: Ophthalmology
Sample Name: Vitrectomy

PREOPERATIVE DIAGNOSIS:,  Vitreous hemorrhage, right eye.,POSTOPERATIVE DIAGNOSIS: , Vitreous hemorrhage, right eye.,PROCEDURE:  ,Vitrectomy, right eye.,PROCEDURE IN DETAIL:  ,The patient was prepared and draped in the usual manner for a vitrectomy procedure under local anesthesia.  Initially, a 5 cc retrobulbar injection was performed with 2% Xylocaine during monitored anesthesia control.  A Lancaster lid speculum was applied and the conjunctiva was opened 4 mm posterior to the limbus.  MVR incisions were made 4 mm posterior to the limbus in the *** and *** o'clock meridians following which the infusion apparatus was positioned in the *** o'clock site and secured with a 5-0 Vicryl suture.  Then, under indirect ophthalmoscopic control, the vitrector was introduced through the *** o'clock site and a complete vitrectomy was performed.  All strands of significance were removed.  Tractional detachment foci were apparent posteriorly along the temporal arcades.  Next, endolaser coagulation was applied to ischemic sites and to neovascular foci under indirect ophthalmoscopic control.  Finally, an air exchange procedure was performed, also under indirect ophthalmoscopic control.  The intraocular pressure was within the normal range.  The globe was irrigated with a topical antibiotic.  The MVR incisions were closed with 7-0 Vicryl.  No further manipulations were necessary.  The conjunctiva was closed with 6-0 plain catgut.  An eye patch was applied and the patient was sent to the recovery area in good condition.
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DESCRIPTION: Vitreous hemorrhage, right eye.  Vitrectomy, right eye.  A Lancaster lid speculum was applied and the conjunctiva was opened 4 mm posterior to the limbus.

ophthalmology, ophthalmoscopic, vitrectomy, endolaser, lancaster lid speculum, vitreous hemorrhage, vitreous, hemorrhage, conjunctiva

A vitrectomy is a surgical procedure performed to treat eye conditions like vitreous hemorrhage and involves the removal of the vitreous gel from the eye. While this is a common procedure in ophthalmology, any surgery involving the eye carries inherent risks such as retinal detachment, infection, or impaired vision, which could potentially lead to permanent vision loss if complications arise. However, in specialized settings with trained professionals, these risks are generally well-managed. The stakes for the patient are significant given the potential impact on vision and quality of life if something goes wrong, making this a moderate to high-stakes situation. However, it is not the highest stakes since it is a standard procedure with established protocols and experienced professionals to manage it.


Medical Specialty: General Medicine
Sample Name: Chronic Medical Conditions - Followup

REASON FOR VISIT: , Followup evaluation and management of chronic medical conditions.,HISTORY OF PRESENT ILLNESS:,  The patient has been doing quite well since he was last seen.  He comes in today with his daughter.  He has had no symptoms of CAD or CHF.  He had followup with Dr. X and she thought he was doing quite well as well.  He has had no symptoms of hyperglycemia or hypoglycemia.  He has had no falls.  His right knee does pain him at times and he is using occasional doses of Tylenol for that.  He wonders whether he could use a knee brace to help him with that issue as well.  His spirits are good.  He has had no incontinence.  His memory is clear, as is his thinking.,MEDICATIONS:,1.  Bumex - 2 mg daily.,2.  Aspirin - 81 mg daily.,3.  Lisinopril - 40 mg daily.,4.  NPH insulin - 65 units in the morning and 25 units in the evening.,5.  Zocor - 80 mg daily.,6.  Toprol-XL - 200 mg daily.,7.  Protonix - 40 mg daily.,8.  Chondroitin/glucosamine - no longer using.,MAJOR FINDINGS:,  Weight 240, blood pressure by nurse 160/80, by me 140/78, pulse 91 and regular, and O2 saturation 94%.  He is afebrile.  JVP is normal without HJR.  CTAP.  RRR.  S1 and S2.  Aortic murmur unchanged.  Abdomen:  Soft, NT without HSM, normal BS.  Extremities:  No edema on today's examination.  Awake, alert, attentive, able to get up on to the examination table under his own power.  Able to get up out of a chair with normal get up and go.  Bilateral OA changes of the knee.,Creatinine 1.7, which was down from 2.3.  A1c 7.6 down from 8.5.  Total cholesterol 192, HDL 37, and triglycerides 487.,ASSESSMENTS:,1.  Congestive heart failure, stable on current regimen.  Continue.,2.  Diabetes type II, A1c improved with increased doses of NPH insulin.  Doing self-blood glucose monitoring with values in the morning between 100 and 130.  Continue current regimen.  Recheck A1c on return.,3.  Hyperlipidemia, at last visit, he had 3+ protein in his urine.  TSH was normal.  We will get a 24-hour urine to rule out nephrosis as the cause of his hypertriglyceridemia.  In the interim, both Dr. X and I have been considering together as to whether the patient should have an agent added to treat his hypertriglyceridemia.  Specifically we were considering TriCor (fenofibrate).  Given his problems with high CPK values in the past for now, we have decided not to engage in that strategy.  We will leave open for the future.  Check fasting lipid panel today.,4.  Chronic renal insufficiency, improved with reduction in dose of Bumex over time.,5.  Arthritis, stable.  I told the patient he could use Extra Strength Tylenol up to 4 grams a day, but I suggest that he start with a regular dose of 1 to 2 to 3 grams per day.  He states he will inch that up slowly.  With regard to a brace, he stated he used one in the past and that did not help very much.  I worry a little bit about the tourniquet type effect of a brace that could increase his edema or put him at risk for venous thromboembolic disease.  For now he will continue with his cane and walker.,6.  Health maintenance, flu vaccination today.,PLANS: , Followup in 3 months, by phone sooner as needed.
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DESCRIPTION: Followup evaluation and management of chronic medical conditions.  Congestive heart failure, stable on current regimen.  Diabetes type II, A1c improved with increased doses of NPH insulin.  Hyperlipidemia, chronic renal insufficiency, and arthritis.

general medicine, congestive heart failure, diabetes, hyperlipidemia, chronic renal insufficiency, arthritis, chronic medical conditions, heart,

The situation involves a routine follow-up evaluation for stable chronic medical conditions such as congestive heart failure, diabetes, and hyperlipidemia. There are no immediate life-threatening issues or drastic changes in the patient's condition noted. The care plan includes ongoing monitoring, and although there are important health concerns being managed, they are not currently in a state of acute crisis or emergency. Therefore, while important for long-term health maintenance and quality of life, the situation is not high-stakes in the sense of requiring urgent or emergency intervention.


Medical Specialty: General Medicine
Sample Name: Gen Med Consult - 11

CHIEF COMPLAINT:,1.  Infection.,2.  Pelvic pain.,3.  Mood swings.,4.  Painful sex.,HISTORY OF PRESENT ILLNESS:,  The patient is a 29-year-old female who is here today with the above-noted complaints.  She states that she has been having a lot of swelling and infection in her inner thigh area with the folliculitis she has had in the past.  She is requesting antibiotics.  She has been squeezing them and some of them are very bruised and irritated.  She also states that she is having significant pelvic pain and would like to go back and see Dr. XYZ again.  She also states that she took herself off of lithium, but she has been having significant mood swings, anger outbursts and not dealing with the situation well at all.  She also has had some psychiatric evaluation, but she states that she did not feel like herself on the medication, so she took herself off.  She states she does not wish to be on any medication at the current time.  She otherwise states that sex is so painful that she is unable to have sex with her husband, even though she "wants to.",PAST MEDICAL HISTORY:,  Significant for cleft palate.,ALLERGIES:,  She is allergic to Lortab.,CURRENT MEDICATIONS:,  None.,REVIEW OF SYSTEMS:,  Please see history of present illness.,Psychiatric:  She has had some suicidal thoughts, but no plans.  She denies being suicidal at the current time.,Cardiopulmonary:  She has not had any chest pain or shortness of breath.,GI:  Denies any nausea or vomiting.,Neurological:  No numbness, weakness or tingling.,PHYSICAL EXAMINATION:,General:  The patient is a well-developed, well-nourished, 29-year-old female who is in no acute distress.,Vital signs:  Weight:  160 pounds.  Blood pressure:  100/60.  Pulse:  62.,Psychiatric:  I did spend over 25 minutes face-to-face with the patient talking about the situation she was in and the medication and her discontinuing use of that.,Extremities:  Her inner thighs are covered with multiple areas of folliculitis and mild abscesses.  They are bruised from her squeezing them.  We talked about that in detail.,ASSESSMENT:,1.  Folliculitis.,2.  Pelvic pain.,3.  Mood swings.,4.  Dyspareunia.,PLAN:,1.  I would like her to go to the lab and get a CBC, chem-12, TSH and UA.,2.  We will put her on cephalexin 500 mg three times a day.,3.  We will send her back to see Dr. XYZ regarding the pelvic pain per her request.,4.  We will get her an appointment with a psychiatrist for evaluation and treatment.,5.  She is to call if she has any further problems or concerns.  Otherwise I will see her back for her routine care or sooner if there are any further issues.
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DESCRIPTION: Infection (folliculitis), pelvic pain, mood swings, and painful sex (dyspareunia).

The situation involves complex medical issues, including infection, pelvic pain, mental health concerns, and painful intercourse. The patient has a history of serious psychiatric symptoms, such as mood swings and previous suicidal thoughts, and has discontinued lithium on her own, which could exacerbate her psychiatric symptoms. Additionally, unmanaged physical symptoms affect her quality of life. There is a plan for further evaluation and treatment, but the presence of multiple interconnected health issues, especially the psychiatric component, elevates the stakes. However, immediate life-threatening conditions are not indicated in this context, which is why it is not at the highest level of stakes.


Medical Specialty: Physical Medicine - Rehab
Sample Name: EMG/Nerve Conduction Study - 7

HISTORY: , The patient is a 34-year-old right-handed female who states her symptoms first started after a motor vehicle accident in September 2005.  She may have had a brief loss of consciousness at the time of the accident since shortly thereafter she had some blurred vision, which lasted about a week and then resolved.  Since that time she has had right low neck pain and left low back pain.  She has been extensively worked up and treated for this.  MRI of the C & T spine and LS spine has been normal.  She has improved significantly, but still complains of pain.  In June of this year she had different symptoms, which she feels are unrelated.  She had some chest pain and feeling of tightness in the left arm and leg and face.  By the next morning she had numbness around her lips on the left side and encompassing the whole left arm and leg.  Symptoms lasted for about two days and then resolved.  However, since that time she has had intermittent numbness in the left hand and leg.  The face numbness has completely resolved.  Symptoms are mild.  She denies any previous similar episodes.  She denies associated dizziness, vision changes incoordination, weakness, change in gait, or change in bowel or bladder function.  There is no associated headache.,Brief examination reveals normal motor examination with no pronator drift and no incoordination.  Normal gait.  Cranial nerves are intact.  Sensory examination reveals normal facial sensation.  She has normal and symmetrical light touch, temperature, and pinprick in the upper extremities.  In the lower extremities she has a feeling of dysesthesia in the lateral aspect of the left calf into the lateral aspect of the left foot.  In this area she has normal light touch and pinprick.  She describes it as a strange unusual sensation.,NERVE CONDUCTION STUDIES: , Motor and sensory distal latencies, evoked response amplitudes, conduction velocities, and F-waves are normal in the left arm and leg.,NEEDLE EMG: , Needle EMG was performed in the left leg, lumbosacral paraspinal, right tibialis anterior, and right upper thoracic paraspinal muscles using a disposable concentric needle.  It revealed normal insertional activity, no spontaneous activity, and normal motor unit action potential form in all muscles tested.,IMPRESSION: , This electrical study is normal.  There is no evidence for peripheral neuropathy, entrapment neuropathy, plexopathy, or lumbosacral radiculopathy.  EMG was also performed in the right upper thoracic paraspinal where she has experienced a lot of pain since the motor vehicle accident.  This was normal.,Based on her history of sudden onset of left face, arm, and leg weakness as well as a normal EMG and MRI of her spine I am concerned that she had a central event in June of this year.  Symptoms are now very mild, but I have ordered an MRI of the brain with and without contrast and MRA of the head and neck with contrast to further elucidate her symptoms.  Once she has the test done she will phone me and further management will be based on the results.
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DESCRIPTION: Patient had movor vehicle accirdent and may have had a brief loss of consciousness.  Shortly thereafter she had some blurred vision,  Since that time she has had right low neck pain and left low back pain.

physical medicine - rehab, nerve conduction studies, motor, sensory, distal latencies, evoked response, conduction velocities, needle emg, loss of consciousness, motor vehicle accident, thoracic paraspinal, needle, paraspinal, conduction,

The medical situation involves a patient with neurological symptoms following a motor vehicle accident. The symptoms included episodes suggesting possible transient ischemic attacks (TIAs) or minor strokes, such as numbness and weakness on the left side of the body. While the immediate tests (EMG and MRI of the spine) are normal, there is a concern about a 'central event,' prompting further investigation with a brain MRI and MRA to rule out serious conditions like stroke. The stakes are high because if these symptoms are related to a stroke or another serious neurological condition, timely diagnosis and treatment are critical to prevent further complications or permanent damage.


Medical Specialty: Nephrology
Sample Name: End Stage Renal Disease - Consult

REASON FOR CONSULTATION: , Management of end-stage renal disease (ESRD), the patient on chronic hemodialysis, being admitted for chest pain.,HISTORY OF PRESENT ILLNESS:,  This is a 66-year-old Native American gentleman, a patient of Dr. X, my associate, who has a past medical history of coronary artery disease, status post stent placement, admitted with chest pressure around 4 o'clock last night.  He took some nitroglycerin tablets at home with no relief.  He came to the ER.  He is going to have a coronary angiogram done today by Dr. Y. I have seen this patient first time in the morning, approximately around the 4 o'clock.  This is a late entry dictation.  Presently lying in bed, but he feels fine.  Denies any chest pain, shortness of breath, nausea, vomiting, abdominal pain, diarrhea.  Denies hematuria, dysuria, or bright red blood per rectum.,PAST MEDICAL HISTORY:,1.  Coronary artery disease, status post stent placement two years ago.,2.  Diabetes mellitus for the last 12 years.,3.  Hypertension.,4.  End-stage renal disease.,5.  History of TIA in the past.,PAST SURGICAL HISTORY:,1.  As mentioned above.,2.  Cholecystectomy.,3.  Appendectomy.,4.  Right IJ PermaCath placement.,5.  AV fistula graft in the right wrist.,PERSONAL AND SOCIAL HISTORY:,  He smoked 2 to 3 packets per day for at least last 10 years.  He quit smoking roughly about 20 years ago.  Occasional alcohol use.,FAMILY HISTORY: , Noncontributory.,ALLERGIES:  ,No known drug allergies.,MEDICATIONS AT HOME: , Metoprolol, Plavix, Rocaltrol, Lasix, Norvasc, Zocor, hydralazine, calcium carbonate, and loratadine.,PHYSICAL EXAMINATION,GENERAL:  He is alert, seems to be in no apparent distress.,VITAL SIGNS:  Temperature 98.2, pulse 61, respiratory 20, and blood pressure 139/63.,HEENT:  Atraumatic and normocephalic.,NECK:  No JVD, no thyromegaly, supra and infraclavicular lymphadenopathy.,LUNGS:  Clear to auscultation.  Air entry bilateral equal.,HEART:  S1 and S2.  No pericardial rub.,ABDOMEN:  Soft and nontender.  Normal bowel sounds.,EXTREMITIES:  No edema.,NEUROLOGIC:  The patient is alert without focal deficit.,LABORATORY DATA:,  Laboratory data shows hemoglobin 13, hematocrit 38.4, sodium 130, potassium 4.2, chloride 96.5, carbonate 30, BUN 26, creatinine 6.03, and glucose 162.,IMPRESSION:,1.  End-stage renal disease, plan for dialysis today.,2.  Diabetes mellitus.,3.  Chest pain for coronary angiogram today.,4.  Hypertension, blood pressure stable.,PLAN: , Currently follow the patient.  Dr. Z is going to assume the care.
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DESCRIPTION: Management of end-stage renal disease (ESRD), the patient on chronic hemodialysis, being admitted for chest pain.

The patient is dealing with multiple serious health conditions including end-stage renal disease (ESRD) and coronary artery disease. They have been admitted for chest pain, a potential sign of a serious cardiac event, which is particularly concerning given their history of coronary artery disease and past stent placement. The combination of these medical issues with the potential for a life-threatening cardiac event makes this a high-stakes situation. Moreover, the patient is set to undergo a coronary angiogram, a procedure that carries its own risks, especially in a patient with ESRD and other comorbidities.


Medical Specialty: Surgery
Sample Name: I&D - Gluteal Abscess

PREOPERATIVE DIAGNOSES,1.  Postoperative wound infection.,2.  Left gluteal abscess.,3.  Intraperitoneal pigtail catheter.,POSTOPERATIVE DIAGNOSES,1.  Postoperative wound infection.  There was an intraperitoneal foreign body.,2.  Left gluteal abscess.,3.  Intraperitoneal pigtail catheter.,PROCEDURES,1.  Incision and drainage (I&D) of gluteal abscess.,2.  Removal of pigtail catheter.,3.  Limited exploratory laparotomy with removal of foreign body and lysis of adhesions.,DESCRIPTION OF PROCEDURE: , After obtaining the informed consent, the patient was transferred to the operating room where a time-out process was followed.  Under general endotracheal anesthesia, first of all the patient was positioned in the left lateral decubitus and the left gluteal area was prepped and draped in the usual fashion.  The opening of the abscess was probed and there was a tract of about 20 cm going subcutaneously upward.  I proceeded to enlarge the drainage area and to some degree unroofing the tract partially and then the area was débrided and then packed with iodoform gauze and a temporary dressing was applied.,Then, the patient was placed in a supine position, and I proceeded to remove the pigtail catheter after dividing it to undo its locking mechanism.  It came out without any difficulty.  Then, the colostomy was protected and draped apart, and the patient's abdomen was prepped and draped in the usual fashion.  My initial idea was to just drain and debride the wound infection, which had a sinus tract at lower end of the midline incision.  I initially probed the wound with a hemostat and this had at least 12 cm long tract and I proceeded to excise the badly scarred skin that was on top of it and then continued the dissection to the fascia and I realized that the sinus tract was going through the fascia into the abdomen.  Very carefully, I started dividing the fascia.  Of course, there were several small bowel loops adhered to the area.  The dissection was quite tedious for a while.  Initially, I thought that may be there was an enterocutaneous fistula in the area, but then I realized that the tissue that was interpreted as an intestinal mucosa was actually a very smooth __________ tissue that was walling the sinus tract.  I made a laparotomy of about 10 cm and I carefully dissected the bowel of the fascia.  There was an area at the bottom which looked like a foreign body and initially I thought there was a mesh that can be used to close the abdomen, but later on this substance floated out by self and it was an elongated strip, maybe about 6 cm, which we sent to Pathology for examination.  Initially, I have obtained a sample for culture and sensitivity for aerobic and anaerobic organisms.,I was very happy that we were not really dealing with enterocutaneous fistula.  The area was irrigated generously with saline and then we closed the fascia with number of interrupted figure-of-eight sutures of heavy PPS.  The subcutaneous tissue and the skin were left open and packed with Betadine-soaked sponges.,A dressing was applied.  A small dressing was applied to the area where we removed the pigtail catheter and also we went down to the gluteal area and put a formal dressing in that area.  The patient tolerated the procedure well.  Estimated blood loss was minimal, and he was sent to the ICU and also made acute care because of the need for a laparotomy, which we were not anticipating.
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DESCRIPTION: Incision and drainage (I&D) of gluteal abscess.  Removal of pigtail catheter.  Limited exploratory laparotomy with removal of foreign body and lysis of adhesions.

surgery, intraperitoneal pigtail catheter, postoperative wound infection, foreign body, intraperitoneal, exploratory laparotomy, enterocutaneous fistula, wound infection, sinus tract, gluteal abscess, pigtail catheter, i&d, abscess, laparotomy, fascia, pigtail, catheter, gluteal, incision, foreign

The situation described involves a surgical procedure which includes incision and drainage of a gluteal abscess, removal of a pigtail catheter, a limited exploratory laparotomy, and removal of a foreign body. These procedures are significant, involving anesthesia and exploratory surgery, which can have serious complications if not handled correctly. The patient requires monitoring in the ICU post-surgery, indicating the seriousness of the procedure. Although the patient tolerated the procedure well and the estimated blood loss was minimal, the stakes are still high due to the complexity and potential risks involved.


Medical Specialty: Emergency Room Reports
Sample Name: Mastoiditis - Discharge Summary

DISCHARGE DIAGNOSES:  ,1.  Suspected mastoiditis ruled out.,2.  Right acute otitis media.,3.  Severe ear pain resolving.,HISTORY OF PRESENT ILLNESS: , The patient is an 11-year-old male who was admitted from the ER after a CT scan suggested that the child had mastoiditis.  The child has had very severe ear pain and blood draining from the right ear.  The child had a temperature maximum of 101.4 in the ER.  The patient was admitted and started on IV Unasyn, which he tolerated well and required Morphine and Vicodin for pain control.  In the first 12 hours after admission, the patient's pain decreased and also swelling of his cervical area decreased.  The patient was evaluated by Dr. X from the ENT while in house.  After reviewing the CT scan, it was felt that the CT scan was not consistent with mastoiditis.  The child was continued on IV fluid and narcotics for pain as well as Unasyn until the time of discharge.  At the time of discharge his pain is markedly decreased about 2/10 and swelling in the area has improved.  The patient is also able to take p.o. well.,DISCHARGE PHYSICAL EXAMINATION:,GENERAL:  The patient is alert, in no respiratory distress.,VITAL SIGNS:  His temperature is 97.6, heart rate 83, blood pressure 105/57, respiratory rate 16 on room air.,HEENT:  Right ear shows no redness.  The area behind his ear is nontender.  There is a large posterior chains node that is nontender and the swelling in this area has decreased markedly.,NECK:  Supple.,CHEST:  Clear breath sounds.,CARDIAC:  Normal S1, S2 without murmur.,ABDOMEN:  Soft.  There is no hepatosplenomegaly or tenderness.,SKIN:  Warm and well perfused.,DISCHARGE WEIGHT: , 38.7 kg.,DISCHARGE CONDITION: , Good.,DISCHARGE DIET:,  Regular as tolerated.,DISCHARGE MEDICATIONS:  ,1.  Ciprodex Otic Solution in the right ear twice daily.,2.  Augmentin 500 mg three times daily x10 days.,FOLLOW UP:  ,1.  Dr. Y in one week (ENT).,2.  The primary care physician in 2 to 3 days.,TIME SPENT: , Approximate discharge time is 28 minutes.
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DESCRIPTION: Suspected mastoiditis ruled out, right acute otitis media, and severe ear pain resolving.  The patient is an 11-year-old male who was admitted from the ER after a CT scan suggested that the child had mastoiditis.

The situation involves an 11-year-old child who was admitted due to a suspected serious condition, mastoiditis, which was ruled out. The child was diagnosed with right acute otitis media and severe ear pain, both of which improved with treatment. The child was not in respiratory distress, and by discharge, his condition had improved significantly. While ear infections can be painful and should be monitored, especially in children, the condition did not necessitate emergency or life-threatening intervention once treated properly and was resolving at discharge. Therefore, while initially concerning, the immediate high-stakes nature of the situation has been reduced.


Medical Specialty: Radiology
Sample Name: CT Head - 1

EXAM:,  CT head.,REASON FOR EXAM:,  Seizure disorder.,TECHNIQUE:,  Noncontrast CT head.,FINDINGS: , There is no evidence of an acute intracranial hemorrhage or infarction.  There is no midline shift, intracranial mass, or mass effect.  There is no extra-axial fluid collection or hydrocephalus.  Visualized portions of the paranasal sinuses and mastoid air cells appear clear aside from mild right frontal sinus mucosal thickening.,IMPRESSION:,  No acute process in the brain.
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DESCRIPTION: Noncontrast CT head due to seizure disorder.

radiology, mass effect, extra-axial fluid, hydrocephalus, midline shift, intracranial mass, paranasal sinuses, mastoid air cells, frontal sinus, mucosal thickening, seizure disorder, ct head, seizure, sinuses, ct, head, noncontrast,

The CT scan was performed on a patient with a seizure disorder to assess if there’s an acute intracranial issue. The findings indicate there is no evidence of acute intracranial hemorrhage, infarction, mass, or any immediate threat such as a shift in midline structures. This suggests that the situation is stable and does not require immediate intervention, indicating lower stakes compared to scenarios with immediate life-threatening findings.


Medical Specialty: Surgery
Sample Name: Vertebroplasty

PREOPERATIVE DIAGNOSIS:,  T11 compression fracture with intractable pain.,POSTOPERATIVE DIAGNOSIS:,  T11 compression fracture with intractable pain.,OPERATION PERFORMED:,  Unilateral transpedicular T11 vertebroplasty.,ANESTHESIA:,  Local with IV sedation.,COMPLICATIONS:,  None.,SUMMARY: , The patient in the operating room in the prone position with the back prepped and draped in the sterile fashion.  The patient was given sedation and monitored.  Using AP and lateral fluoroscopic projections the T11 compression fracture was identified.  Starting from the left side local anesthetic was used for skin wheal just lateral superior to the 10 o'clock position of the lateral aspect of the T11 pedicle on the left.  The 13-gauge needle and trocar were then taken and placed to 10 o'clock position on the pedicle.  At this point using AP and lateral fluoroscopic views, the needle and trocar were advanced into the vertebral body using the fluoroscopic images and making sure that the needle was lateral to the medial wall of the pedicle of the pedicle at all times.  Once the vertebral body was entered then using lateral fluoroscopic views, the needle was advanced to the junction of the anterior one third and posterior two thirds of the body.  At this point polymethylmethacrylate was mixed for 60 seconds.  Once the consistency had hardened and the __________ was gone, incremental dose of the cement were injected into the vertebral body.  It was immediately seen that the cement was going cephalad into the vertebral body and was exiting through the crack in the vertebra.  A total 1.2 cc of cement was injected.  On lateral view, the cement crushed to the right side as well.  There was some dye infiltration into the disk space.  There was no dye taken whatsoever into the posterior aspect of the epidural space or intrathecal canal.,At this point, as the needle was slowly withdrawn under lateral fluoroscopic images, visualization was maintained to ensure that none of the cement was withdrawn posteriorly into the epidural space.  Once the needle was withdrawn safely pressure was held over the site for three minutes.  There were no complications.  The patient was taken back to the recovery area in stable condition and kept flat for one hour.  Should be followed up the next morning.
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DESCRIPTION: Unilateral transpedicular T11 vertebroplasty.

surgery, transpedicular, vertebroplasty, fluoroscopic views, fluoroscopic images, epidural space, compression fracture, vertebral body, compression, pedicle, fluoroscopic, vertebral, needle

The description involves a surgical procedure (vertebroplasty) to address a T11 compression fracture with intractable pain. Given the nature of surgery, there are inherent risks involved such as potential damage to neural structures, infection, or adverse reaction to anesthesia, even though in this case no complications were reported. The procedure also shows complexity in terms of surgical technique. However, since the procedure is done with local anesthesia and no immediate complications occurred, it does not represent the highest level of stakes as compared to other life-threatening scenarios encountered in surgery.


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

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

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

The situation involves a surgical procedure, specifically an anterior cervical discectomy and fusion, which is inherently high-stakes due to the complexity and risks involved. Surgical procedures always carry risks such as infection, hemorrhage, and complications from anesthesia, and in this case, potential spinal and neurological complications. The age of the patient (62) adds another layer of risk, and the procedure's potential impacts on the spinal cord make it critical. Surgery generally involves high-risk factors given the possible severe consequences of complications.


Medical Specialty: Surgery
Sample Name: Mass Excision - Foot

PREOPERATIVE DIAGNOSIS: , Soft tissue mass, right foot.,POSTOPERATIVE DIAGNOSIS: , Soft tissue mass, right foot.,PROCEDURE PERFORMED: , Excision of soft tissue mass, right foot.,HISTORY:  ,The patient is a 51-year-old female with complaints of soft tissue mass over the dorsum of the right foot.  The patient has had previous injections to the site which have caused the mass to decrease in size, however, the mass continues to be present and is irritated and painful with shoes.  The patient has requested surgical intervention at this time.,PROCEDURE:  ,After an IV was instituted by the Department of Anesthesia, the patient was escorted from the preoperative holding area to the operating room.  The patient was then placed on the operating room table in the supine position and a towel was placed around the patient's abdomen and secured her to the table.  Using copious amounts of Webril, a pneumatic ankle tourniquet was applied to her right ankle.  Using a Skin Skribe, the area of the soft tissue mass was outlined over the dorsum of her foot.  After adequate amount of anesthesia was provided by the Department of Anesthesia, a local ankle block was given using 10 cc of 4.5 mL of 1% lidocaine plain, 4.5 mL of 0.5% Marcaine plain and 1.0 mL of Solu-Medrol and the foot was scrubbed and prepped in a normal sterile orthopedic manner.  Following this, the ankle was elevated and Esmarch bandage applied to exsanguinate the foot and the ankle tourniquet was inflated to 250 mmHg.  The foot was then brought back down to the table using bandage scissors.  The stockinette was reflected and the right foot was exposed.  Using a fresh #10 blade, a curvilinear incision was performed over the dorsum of the right foot.  Then using a #15 blade, the incision was deepened with care taken to identify and avoid or cauterize any bleeders which were noted.  Following this, the incision was deepened using a combination of sharp and blunt dissection and the muscle belly of the extensor digitorum brevis muscle was identified.  Further dissection was then performed in the medial direction in the area of the soft tissue mass.  The intermediate dorsal cutaneous nerve was identified and gently retracted laterally.  Large amounts of adipose tissue were noted medial to the belly of the extensor digitorum brevis muscle.  Using careful dissection, adipose tissue in this area was removed and saved for pathology.  Following removal of adipose tissue in this area and identification of no more adipose tissue, attention was directed lateral to the belly of the extensor digitorum brevis muscle, which was also noted to have large amounts of adipose tissue in this area as well.  Using careful dissection, from the lateral border of the foot as much adipose tissue as possible was removed from this area as well and saved for pathology.  There was noted to be no other fluid-filled masses or lesions identifiable in this area then between the slits of the extensor digitorum brevis muscle, careful dissection was performed to examine the underside of the belly of the muscle as well as structures beneath and no abnormal structures were identified here as well.  Following this, feeling adequately that no other mass remained in the area, the incision was flushed using copious amounts of sterile saline.  The wound was then reinspected and all remaining tissues appeared healthy including the subcutaneous tissue.  The tendon and muscle belly of the extensor digitorum brevis muscle, the nerves of the intermediate dorsal cutaneous nerve and also the medial dorsal cutaneous nerve which were identified medially, all appeared intact.  No deficits were noted.  No abnormal appearing tissue was present within the surgical site.  Following this, the skin edges were reapproximated using #4-0 Vicryl deep closure of the subcutaneous layer was performed.  Then, using #4-0 nylon and simple interrupted suture, the skin was reapproximated and closed with care taken to ensure eversion of the skin edges and good approximation of the borders.  The patient was also given 7 cc of 1% lidocaine plain throughout the procedure to augment local anesthesia.  Following this, the wound was dressed using Xeroform gauze and 4x4s and was dressed using two ABD pads, dorsal and plantar for compression and using Kling, Kerlix and Coban.  The patient then had the ankle tourniquet deflated with a total tourniquet time of 55 minutes at 250 mmHg and immediate hyperemia was noted to digits one through five of the right foot.  The patient tolerated the procedure and anesthesia well and was noted to have vascular status intact.  The patient was then escorted to the Postanesthesia Care Unit where she was placed in a surgical shoe.  The patient was then given postoperative instructions to include ice and elevation to her right foot.  The patient was cleared for ambulation as tolerated, but was instructed that with increased ambulation will come increased swelling and pain.  The patient will follow up with Dr. X in his office on Tuesday, 08/26/03 for further follow up.  The patient was given prescription for Vicoprofen #25 taken one tablet q.4h. p.r.n., moderate to severe pain and also prescription for Keflex #20 500 mg tablets to be taken b.i.d. x10 days.  The patient was given a number for the Emergency Room and instructed to return if any sign or symptom of infection should present and the patient was educated as to the nature of these.  The patient had no further questions and recovered without any complications in the Postanesthesia Care Unit.
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DESCRIPTION: Excision of soft tissue mass, right foot.  The patient is a 51-year-old female with complaints of soft tissue mass over the dorsum of the right foot.

surgery, excision, digitorum brevis muscle, soft tissue mass, adipose tissue, soft tissue, mass, injections, foot, tissue, xeroform, dorsum, belly, extensor, digitorum, brevis, ankle, adipose, muscle,

The procedure described is a routine surgical excision of a soft tissue mass from the foot, which is generally considered low to moderate in terms of stakes. It is a common surgical intervention with standard risks typical of any surgery, including infection or bleeding, but it does not involve critical or life-threatening conditions. The post-operative instructions and follow-up indicate that no major complications are expected. While the procedure requires skill and care, it is not high-stakes compared to surgeries involving vital organs or high-risk conditions.


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

Medical Specialty: Radiology
Sample Name: Cerebral Angiogram - Lateral Medullary Syndrome

CC: ,Falling to left.,HX:, 26y/oRHF fell and struck her head on the ice 3.5 weeks prior to presentation. There was no associated loss of consciousness. She noted a dull headache and severe sharp pain behind her left ear 8 days ago. The pain lasted 1-2 minutes in duration. The next morning she experienced difficulty walking and consistently fell to the left. In addition the left side of her face had become numb and she began choking on food. Family noted her pupils had become unequal in size. She was seen locally and felt to be depressed and admitted to a psychiatric facility. She was subsequently transferred to UIHC following evaluation by a local ophthalmologist.,MEDS:, Prozac and Ativan (both recently started at the psychiatric facility).,PMH: ,1) Right esotropia and hyperopia since age 1year. 2) Recurrent UTI.,FHX:, Unremarkable.,SHX:, Divorced. Lives with children. No spontaneous abortions. Denied ETOH/Tobacco/Illicit Drug use.,EXAM:, BP 138/110.  HR 85.  RR 16.  Temp 37.2C.,MS: A&O to person, place, time. Speech fluent and without dysarthria. Intact naming, comprehension, repetition.,CN: Pupils 4/2 decreasing to 3/1 on exposure to light. Optic Disks flat. VFFTC. Esotropia OD, otherwise EOM full. Horizontal nystagmus on leftward gaze. Decreased corneal reflex, OS. Decreased PP/TEMP sensation on left side of face. Light touch testing normal. Decreased gag response on left. Uvula deviates to right. The rest of the CN exam was unremarkable.,Motor: 5/5 strength throughout with normal muscle bulk and tone.,Sensory: Decreased PP and TEMP on right side of body. PROP/VIB intact.,Coord: Difficulty with FNF/HKS/RAM on left. Normal on right side.,Station: No pronator drift. Romberg test not noted.,Gait: unsteady with tendency to fall to left.,Reflexes: 3/3 throughout BUE and Patellae. 2+/2+ Achilles. Plantar responses were flexor, bilaterally.,Gen Exam: Obese. In no acute distress. Otherwise unremarkable.,HEENT: No carotid/vertebral/cranial bruits.,COURSE:, PT/PTT, GS, CBC, TSH, FT4 and Cholesterol screen were all within normal limits. HCT on admission was negative. MRI Brain (done locally 2/2/93) was reviewed and a left lateral medullary stroke was appreciated. The patient underwent a cerebral angiogram on 2/3/93 which revealed significant narrowing of the left vertebral artery beginning at C2 and extending to and involving the basilar artery. There is severe, irregular narrowing of the horizontal portion above the posterior arch of C1. The findings were felt consistent with a left vertebral artery dissection. Neuro-opthalmology confirmed a left Horner's pupil by clinical exam and history. Cookie swallow study was unremarkable. The Patient was placed on Heparin then converted to Coumadin. The PT on discharge was 17.,She remained on Coumadin for 3 months and then was switched to ASA for 1 year. An Otolaryngologic evaluation on 10/96 noted true left vocal cord paralysis with full glottic closure. A prosthesis was made and no surgical invention was done.
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DESCRIPTION: Cerebral Angiogram - Lateral medullary syndrome secondary to left vertebral artery dissection.

radiology, horner's pupil, mri brain, otolaryngologic, cerebral angiogram, cerebral angiogram lateral, medullary syndrome, vertebral artery, angiogram, syndrome, falling, narrowing, medullary, vertebral, cerebral,

The case details a radiological examination and treatment plan for a patient with Lateral Medullary Syndrome caused by a left vertebral artery dissection. This condition involves significant neurological symptoms, has a risk of serious complications, and required specific interventions, such as anticoagulation therapy and potentially invasive studies like a cerebral angiogram. The stakes are high because incorrect management could lead to lasting harm or even life-threatening consequences. Proper diagnosis and treatment are crucial to prevent further ischemic events. However, it's not in the very highest category as it appears the condition has been identified and appropriately managed. Also, there was no immediate life-threatening emergency at the time of assessment by radiology.


Medical Specialty: Surgery
Sample Name: Teeth Extraction

PREOPERATIVE DIAGNOSES,1.  Basal cell nevus syndrome.,2.  Cystic lesion, left posterior mandible.,3.  Corrected dentition.,4.  Impacted teeth 1 and 16.,5.  Maxillary transverse hyperplasia.,POSTOPERATIVE DIAGNOSES,1.  Basal cell nevus syndrome.,2.  Cystic lesion, left posterior mandible.,3.  Corrected dentition.,4.  Impacted teeth 1 and 16.,5.  Maxillary transverse hyperplasia.,PROCEDURE,1.  Removal of cystic lesion, left posterior mandible.,2.  Removal of teeth numbers 4, 13, 20, and 29.,3.  Removal of teeth numbers 1 and 16.,4.  Modified Le Fort I osteotomy.,INDICATIONS FOR THE PROCEDURE:, The patient has undergone previous surgical treatment and had a diagnosis of basal cell nevus syndrome.  Currently our plan is to remove the impacted third molar teeth, to remove a cystic lesion left posterior mandible, to remove 4 second bicuspid teeth as requested by her orthodontist, and to weaken and her maxilla to allow expansion by a modified Le Fort osteotomy.,PROCEDURE IN DETAIL:, The patient was brought into the operating room, placed on the operating table in supine position.  Following treatment under adequate general anesthesia via the orotracheal route, the patient was prepped and draped in a manner consistent with intraoral surgical procedures.  The oral cavity was suctioned, was drained of fluid and a throat pack was placed.  General anesthesia nursing service was notified and which was removed at the end of the procedure.  Lidocaine 1% with epinephrine concentration in 1:100,000 was injected into the labial vestibule of the maxilla bilaterally as well as the lateral areas associated with the extractions sites in lower jaw and the left posterior mandible for a total of 11 mL.  A Bovie electrocautery was utilized to make a vestibular incision, beginning in the second molar region of the maxilla superior to the mucogingival junction extending to the area of the cuspid teeth.  Subperiosteal dissection revealed lateral aspect of the maxilla immediately posterior to the second molar tooth where the third molar tooth was identified and was bony crypt.  Following use of Cerebromaxillary osteotome, elevated, and underwent complete removal of the dental follicle.  Secondly, tooth number 4 was removed.  Tooth number 13 was removed, and the opposite third molar tooth was removed through an identical incision on the opposite side.  Surgeon then utilized a #15 saw to make a horizontal osteotomy through the lateral aspect of the maxilla from the target plates, anteriorly to the area of the buttress region cross the anterior maxilla to a point adjacent to the piriform rim, 5 mm superior to the nasal floor, bilaterally Cerebromaxillary osteotome utilized to separate the maxilla from the target placed posteriorly and a 5 mm Tessier osteotome through a vertical incision anteriorly between roots of teeth numbers 8 and 9.  This resulted in the alternate mobilization of the two halves of the maxilla, or to allow expansion.  These wounds were all irrigated with copious amounts of normal saline and with antibiotic containing solution, closed with 3-0 chromic suture in running fashion for watertight closure.  Attention was directed to the mandible where the left posterior mandible was approached through a lateral vestibular incision overlying the external oblique ridge and brought anteriorly in an old scar.  The surgeons utilized cautery osteotome to identify a cystic lesion associated with the left posterior mandible, which was approximately 1 cm in width and 2.5 to 3 cm in vertical dimension immediately adjacent to the neurovascular bundle.  This wound was then irrigated with copious amounts of normal saline and concentrated solution of clindamycin.  Closed primarily with a 3-0 Vicryl suture in running fashion for a watertight closure.  Teeth number 20 and 29 where removed and 3-0 chromic suture placed.  This concluded the procedure.  All cottonoids and other sponges, throat pack were removed.  No complications were encountered.  The aforementioned cystic lesion was sent with specimen no drains were placed.  The blood loss from this procedure was approximately 100 mL.,The patient was returned over the care of the anesthesia where she was extubated in the operating room, taken from the operating room to the recovery room with stable vital signs and spontaneous respirations.
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DESCRIPTION: Removal of cystic lesion, removal of teeth, modified Le Fort I osteotomy.

surgery, nevus syndrome, basal cell, mandible, teeth, hyperplasia, cystic lesion, osteotomy, le fort, le fort osteotomy, orotracheal route, bony crypt, watertight, removal of cystic lesion, le fort i osteotomy, aspect of the maxilla, modified le fort, molar tooth, posterior mandible, maxillary, molar, tooth,

The situation described involves multiple surgical procedures, including the removal of a cystic lesion, impacted teeth extractions, and a modified Le Fort I osteotomy, performed on a patient with basal cell nevus syndrome. These procedures are complex, involving general anesthesia, the risk of complications, and proximity to critical anatomical structures like the neurovascular bundle. The patient's need for recovery and possible complications during or after surgery increase the stakes. However, considering that no complications were reported and the procedures fall within typical surgical treatment scopes, it's not the highest stake case possible.


Medical Specialty: Gastroenterology
Sample Name: Colonoscopy with Biopsy - 1

PREPROCEDURE DIAGNOSIS:,  Change in bowel function.,POSTPROCEDURE DIAGNOSIS:,  Proctosigmoiditis.,PROCEDURE PERFORMED:,  Colonoscopy with biopsy.,ANESTHESIA: , IV sedation.,POSTPROCEDURE CONDITION: , Stable.  ,INDICATIONS:,  The patient is a 33-year-old with a recent change in bowel function and hematochezia.  He is here for colonoscopy.  He understands the risks and wishes to proceed.  ,PROCEDURE: , The patient was brought to the endoscopy suite where he was placed in left lateral Sims position, underwent IV sedation.  Digital rectal examination was performed, which showed no masses, and a boggy prostate.  The colonoscope was placed in the rectum and advanced, under direct vision, to the cecum.  In the rectum and sigmoid, there were ulcerations, edema, mucosal abnormalities, and loss of vascular pattern consistent with proctosigmoiditis.  Multiple random biopsies were taken of the left and right colon to see if this was in fact pan colitis.,RECOMMENDATIONS: , Follow up with me in 2 weeks and we will begin Canasa suppositories.
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DESCRIPTION: The patient with a recent change in bowel function and hematochezia.

gastroenterology, change in bowel function, iv sedation, bowel function, proctosigmoiditis, sedation, rectum, bowel, function, colonoscopy, hematochezia,

The procedure described is a routine medical procedure in gastroenterology involving a colonoscopy with biopsy. While any medical procedure involves some degree of risk, this is a common diagnostic procedure used to identify issues in the colon and rectum. The patient was stable post-procedure, which suggests that the immediate health risks associated with the procedure were low. The conditions mentioned, such as proctosigmoiditis, can generally be managed with medication and monitoring. Hence, the stakes are not extremely high in this context.


Medical Specialty: Pain Management
Sample Name: Radiofrequency Thermocoagulation - 1

PROCEDURE: , Radiofrequency thermocoagulation of bilateral lumbar sympathetic chain.,ANESTHESIA: , Local sedation.,VITAL SIGNS: , See nurse's notes.,COMPLICATIONS: , None.,DETAILS OF PROCEDURE:  ,INT was placed.  The patient was in the operating room in the prone position with the back prepped and draped in a sterile fashion.  The patient was given sedation and monitored.  Lidocaine 1.5% for skin wheal was made 10 cm from the midline to the bilateral L2 distal vertebral body.  A 20-gauge, 15 cm SMK needle was then directed using AP and fluoroscopic guidance so that the tip of the needle was noted to be along the distal one-third and anterior border on the lateral view and on the AP view the tip of the needle was inside the lateral third of the border of the vertebral body.  At this time a negative motor stimulation was obtained.  Injection of 10 cc of 0.5% Marcaine plus 10 mg of Depo-Medrol was performed. Coagulation was then carried out for 90oC for 90 seconds.  At the conclusion of this, the needle under fluoroscopic guidance was withdrawn approximately 5 mm where again a negative motor stimulation was obtained and the sequence of injection and coagulation was repeated.  This was repeated one more time with a 5 mm withdrawal and coagulation.,At that time, attention was directed to the L3 body where the needle was placed to the upper one-third/distal two-thirds junction and the sequence of injection, coagulation, and negative motor stimulation with needle withdrawal one time of a 5 mm distance was repeated.  There were no compilations from this.  The patient was discharged to operating room recovery in stable condition.
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DESCRIPTION: Radiofrequency thermocoagulation of bilateral lumbar sympathetic chain.

pain management, lumbar sympathetic chain, vertebral body, radiofrequency thermocoagulation, motor stimulation, thermocoagulation, radiofrequency, coagulation, needle,

The procedure described, radiofrequency thermocoagulation for pain management, involves invasive medical intervention with potential serious risks if not performed correctly, such as nerve damage or infection. However, in this specific instance, the procedure was performed without complication, and the patient recovered in stable condition. This suggests that while it is a relatively high-stakes procedure due to its potential risks, the situation itself was managed well and resulted in no adverse outcomes.


Medical Specialty: Surgery
Sample Name: Bronchoscopy & Bronchoalveolar Lavage

PREOPERATIVE DIAGNOSIS:,  Refractory pneumonitis.,POSTOPERATIVE DIAGNOSIS: , Refractory pneumonitis.,PROCEDURE PERFORMED: , Bronchoscopy with bronchoalveolar lavage.,ANESTHESIA: , 5 mg of Versed.,INDICATIONS: , A 69-year-old man status post trauma, slightly prolonged respiratory failure status post tracheostomy, requires another bronchoscopy for further evaluation of refractory pneumonitis.,PROCEDURE: , The patient was sedated with 5 mg of Versed that was placed on the endotracheal tube.  Bronchoscope was advanced.  Both right and left mainstem bronchioles and secondary and tertiary bronchioles were cannulated sequentially, lavaged out.  Relatively few tenacious secretions were noted.  These were lavaged out.  Specimen collected for culture.  No obvious other abnormalities were noted.  The patient tolerated the procedure well without complication.
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DESCRIPTION: Bronchoscopy with bronchoalveolar lavage.  Refractory pneumonitis.  A 69-year-old man status post trauma, slightly prolonged respiratory failure status post tracheostomy, requires another bronchoscopy for further evaluation of refractory pneumonitis.

surgery, respiratory failure, bronchoalveolar lavage, refractory pneumonitis, tracheostomy, bronchoalveolar, bronchoscopy, pneumonitis

The situation involves a medical procedure (bronchoscopy with bronchoalveolar lavage) performed on a 69-year-old man post-trauma with refractory pneumonitis. While the procedure is routine and the patient tolerated it well without complications, the context of trauma, respiratory failure, and refractory pneumonitis suggests a serious underlying condition. Therefore, the situation carries moderate to high-stakes, as it directly impacts the patient's ongoing care and condition management.


Medical Specialty: Hematology - Oncology
Sample Name: Thrombocytopenia - SOAP Note

SUBJECTIVE: , I am following the patient today for immune thrombocytopenia.  Her platelets fell to 10 on 01/09/07 and shortly after learning of that result, I increased her prednisone to 60 mg a day.  Repeat on 01/16/07 revealed platelets up at 43.  No bleeding problems have been noted.  I have spoken with her hematologist who recommends at this point we decrease her prednisone to 40 mg for 3 days and then go down to 20 mg a day.  The patient had been on 20 mg every other day at least for a while, and her platelets hovered at least above 20 or so.,PHYSICAL EXAMINATION: , Vitals:  As in chart.  The patient is alert, pleasant, and cooperative.  She is in no apparent distress.  The petechial areas on her legs have resolved.,ASSESSMENT AND PLAN: , Patient with improvement of her platelet count on burst of prednisone.  We will decrease her prednisone to 40 mg for 3 days, then go down to 20 mg a day.  Basically thereafter, over time, I may try to sneak it back a little bit further.  She is on medicines for osteoporosis including bisphosphonate and calcium with vitamin D.  We will arrange to have a CBC drawn weekly.,
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DESCRIPTION: Patient with immune thrombocytopenia

Patient with immune thrombocytopenia

hematology - oncology, platelets, platelet count, thrombocytopenia, prednisone,

The situation involves managing a patient's immune thrombocytopenia, a condition that can lead to serious complications if not managed properly. However, the patient is currently stable with controlled symptoms and an appropriate treatment plan in place, including prednisone tapering and monitoring platelet levels. There are no immediate critical issues, such as active bleeding, noted in the case. Hence, while important, it is not extremely high-stakes at the moment.


Medical Specialty: Neurology
Sample Name: Granulomatous Inflammation

CC:, Headache and diplopia.,HX:, This 39 y/o African American female began experiencing severe constant pressure pain type headaches beginning the last week of 8/95. The pain localized to bifronto-temporal regions of the head and did not radiate. There was no associated nausea, vomiting, photophobia or phonophobia. The HA's occurred daily; and throughout daylight hours. They diminished at bedtime, but occasionally awakened her in the morning.,Several days following the onset of her HA's, she began experiencing numbness and tingling about the right side of her face. These symptoms improved, but did not completely resolved.,Several days after the onset of facial paresthesias, she began to experience binocular horizontal diplopia. The diplopia resolved when covering either eye, and worsened upon looking toward the right. Coincidentally, she began veering toward the right when walking. She denied any weakness. She had had chronic unsteadiness for many years since developing juvenile rheumatoid arthritis. She was unsure whether her unsteadiness was due to poor depth perception in light of her diplopia.,The patient was admitted locally 9/2/95. HCT, 9/2/95 and Brain MRI with gadolinium, 9/3/95, were "unremarkable." Lumbar puncture (done locally),9/3/95: Opening pressure 27cm H20, CSF analysis ( protein 14.0, glucose 66, O WBC, 3 RBC, VDRL non-reactive, Lyme titer unremarkable, Myelin basic protein 1.0 (normal <4.0), and there was no evidence of oligoclonal bands. ESR=76. On 9/11/95 ESR=110. Acetylcholine receptor binding and blocking antibodies were negative. 9/4/95, ANA and RF were negative. 7/94, ANA and RF were negative, and ESR=60.,MEDS: ,Tylenol 500mg q5-6hrs. No known Allergies.,PMH:, 1)Juvenile Rheumatoid Arthritis diagnosed at age 10 years; now in remission. 2)Right #5 finger reattachment as child due to traumatic amputation.,FHX: ,Mother died age 42 of unknown type cancer. Father died age 62 of unknown type cancer. 4 sisters, one brother and 2 half-brothers. One of the half-brothers has asthma.,SHX: ,Single, lives with sister, and denies Tobacco/ETOH/illicit drug use.,EXAM:, BP141/84, HR99, RR14, 36.8C, Wt. 82kg Ht. 152.,MS: A&O to person, place, time. Speech fluent; without dysarthria. Mood euthymic with appropriate affect.,CN: Decreased abduction, OD. In neutral gaze, the right eye deviated slightly lateral of midline. In addition, she had mild proptosis, OD. The right eye was nontender to palpation during extraocular movement. Visual fields were full to confrontation. Optic disks appeared flat. Face was symmetric with full movement and sensation. Gag, shoulder shrug and corneal responses were intact, bilaterally. Tongue was midline with full ROM.,MOTOR: 5/5 strength throughout with normal muscle bulk and tone.,SENSORY: Unremarkable.,COORD: Unremarkable FNF/HKS/RAM.,STATION: Unremarkable. NO Romberg's sign or drift.,GAIT: Narrow based gait. Able to TT and HW without difficulty. Mild difficulty with TW.,REFLEXES: 2+/2+ Throughout all 4 extremities. Flexor plantar responses, bilaterally.,Musculoskeletal: Swan neck deformities of the #2 and #3 digits of both hands.,GEN EXAM: unremarkable, except for obvious sign of right finger reattachment (mentioned above).,COURSE: ,Repeat lumbar puncture yielded: Opening pressure 20.25cm H20, protein 22, glucose 62, 2RBC, 1WBC. CSF cytology, ACE, cultures (bacterial, fungal, AFB), gram stain, cryptococcal antigen, and VDRL were negative. Serum ACE, TSH, FT4 were unremarkable.,Neuroophthalmology confirmed her right CN6 palsy and proptosis (OD); and noted her complaint of paresthesias in the V1 and V2 distribution. They saw no evidence of papilledema. Visual field testing was unremarkable. MRI Brain/orbit/neck with gadolinium, 10/20/95, revealed abnormal enhancing signal in the right cavernous sinus and sinus mucosal thickening in both maxillary sinuses/ethmoid sinuses/frontal sinuses. CXR, 10/20/95, showed a lobulated mass arising from the right hilum. The mass appeared to obstruct the right middle lobe, causing partial collapse of this lobe. Chest CT with contrast, 10/23/95, revealed a 3.2x4.5x4.0cm mass in the right hilar region with impingement on the right lower bronchus. There appeared to be calcification as well as low attenuation regions within the mass. No lymphadenopathy was noted. She underwent bronchoscopy with bronchial brushing and transbronchial aspirate of the right lung on 10/24/95: no tumor cells were identified, GMS stains were negative and there was no evidence of viral changes, fungus or PCP by culture or molecular assay. She underwent right maxillary sinus biopsy and right middle lobe wedge resection and lymph node biopsy on 11/2/95: Caseating granulomatous inflammation with associated inflammatory pseudotumor was found in both sinus and lung biopsy specimens. No sign of cancer was found. Tissue cultures (bacterial, fungal, AFB) were negative times 3. The patients case was discussed at Head and Neck Oncology Tumor Board and a differential diagnosis of Sarcoidosis, Histoplasmosis, Wegener's Granulomatosis, were considered. Urine Histoplasmosis Antigen testing on 11/8/95 was 0.9units (normal<1.0): repeat testing on 12/13/95 was 0.8units. ANCA serum titers on 11/8/95 were <1:40 (normal). PPD testing was negative 11/95 (with positive candida and mumps controls).,The etiology of this patient's illness was not discovered. She was last seen 4/96 and her diplopia and right CN6 palsy had moderately improved.
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DESCRIPTION: Headache and diplopia.

Headache and diplopia.

The situation involves a complex medical case with symptoms that could indicate serious neurological or systemic conditions, such as sarcoidosis or vasculitis (e.g., Wegener's Granulomatosis). The patient's symptoms include severe headaches, diplopia, and cranial nerve palsy, which are concerning given that diagnostic tests have not yet revealed the underlying condition. These factors suggest the possibility of an evolving serious condition that could affect the brain or vital functions if not properly diagnosed and managed. However, the immediate life-threatening element is not prominent at this stage. The situation requires careful diagnostic follow-up and management to prevent potential escalation of the condition.


Medical Specialty: Office Notes
Sample Name: Chest Pain - Office Note

DISCHARGE DIAGNOSES:,1.  Chest pain.  The patient ruled out for myocardial infarction on serial troponins.  Result of nuclear stress test is pending.,2.  Elevated liver enzymes, etiology uncertain for an outpatient followup.,3.  Acid reflux disease.,TEST DONE: , Nuclear stress test, results of which are pending.,HOSPITAL COURSE: , This 32-year-old with family history of premature coronary artery disease came in for evaluation of recurrent chest pain, O2 saturation at 94% with both atypical and typical features of ischemia.  The patient ruled out for myocardial infarction with serial troponins.  Nuclear stress test has been done, results of which are pending.  The patient is stable to be discharged pending the results of nuclear stress test and cardiologist's recommendations.  He will follow up with cardiologist, Dr. X, in two weeks and with his primary physician in two to four weeks.  Discharge medications will depend on results of nuclear stress test.
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DESCRIPTION: Patient with a family history of premature coronary artery disease came in for evaluation of recurrent chest pain

office notes, chest pain, serial troponins, premature coronary artery disease, coronary artery disease, nuclear stress test, stress test

The situation involves a patient with a family history of coronary artery disease presenting with chest pain, which is a potential indicator of serious heart conditions. The initial tests have ruled out myocardial infarction, but the results of a nuclear stress test are still pending. The patient's discharge and medication plan depends on these results. Given the potential for serious cardiovascular issues, the situation is moderately high-stakes.


Medical Specialty: Surgery
Sample Name: Patent Ductus Arteriosus Ligation

TITLE OF OPERATION: , Ligation (clip interruption) of patent ductus arteriosus.,INDICATION FOR SURGERY: , This premature baby with operative weight of 600 grams and evidence of persistent pulmonary over circulation and failure to thrive has been diagnosed with a large patent ductus arteriosus originating in the left-sided aortic arch.  She has now been put forward for operative intervention.,PREOP DIAGNOSIS:  ,1.  Patent ductus arteriosus.,2.  Severe prematurity.,3.  Operative weight less than 4 kg (600 grams).,COMPLICATIONS: , None.,FINDINGS: , Large patent ductus arteriosus with evidence of pulmonary over circulation.  After completion of the procedure, left recurrent laryngeal nerve visualized and preserved.  Substantial rise in diastolic blood pressure.,DETAILS OF THE PROCEDURE: , After obtaining information consent, the patient was positioned in the neonatal intensive care unit, cribbed in the right lateral decubitus, and general endotracheal anesthesia was induced.  The left chest was then prepped and draped in the usual sterile fashion and a posterolateral thoracotomy incision was performed.  Dissection was carried through the deeper planes until the second intercostal space was entered freely with no damage to the underlying lung parenchyma.  The lung was quite edematous and was retracted anteriorly exposing the area of the isthmus.  The pleura overlying the ductus arteriosus was inside and the duct dissected in a nearly circumferential fashion.  It was then test occluded and then interrupted with a medium titanium clip.  There was preserved pulsatile flow in the descending aorta.  The left recurrent laryngeal nerve was identified and preserved.  With excellent hemostasis, the intercostal space was closed with 4-0 Vicryl sutures and the muscular planes were reapproximated with 5-0 Caprosyn running suture in two layers.  The skin was closed with a running 6-0 Caprosyn suture.  A sterile dressing was placed.  Sponge and needle counts were correct times 2 at the end of the procedure.  The patient was returned to the supine position in which palpable bilateral femoral pulses were noted.,I was the surgical attending present in the neonatal intensive care unit and in-charge of the surgical procedure throughout the entire length of the case.
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DESCRIPTION: Ligation (clip interruption) of patent ductus arteriosus.  This premature baby with operative weight of 600 grams and evidence of persistent pulmonary over circulation and failure to thrive has been diagnosed with a large patent ductus arteriosus originating in the left-sided aortic arch.

surgery, clip interruption, ligation, patent ductus arteriosus, premature baby, intercostal space, arteriosus, interruption, pulmonary, circulation

The situation involves a surgical procedure on a highly vulnerable premature infant weighing only 600 grams, with a diagnosis of patent ductus arteriosus. Surgical interventions on such a small and delicate patient inherently carry significant risks, including complications from anesthesia, the precision required in the procedure, and postoperative care challenges. Furthermore, the indication for surgery is based on significant health consequences (persistent pulmonary circulation and failure to thrive), highlighting the importance of the procedure for the patient's survival and long-term health. Therefore, the stakes are high both in terms of immediate surgical risks and the potential for improved quality of life following successful intervention.