Medical Specialty: Consult - History and Phy.
Sample Name: Chest Pain - Cardiac Consult

REASON FOR REFERRAL:,  Chest pain, possible syncopal spells.,She is a very pleasant 31-year-old mother of two children with ADD.,She was doing okay until January of 2009 when she had a partial hysterectomy.  Since then she just says "things have changed".  She just does not want to go out anymore and just does not feel the same.  Also, at the same time, she is having a lot of household stressors with both of her children having ADD and ODD and she feels she does not get enough support from her husband.  Her 11-year-old is having a lot of trouble at school and she often has to go there to take care of problems.,In this setting, she has been having multiple cardiovascular complaints including chest pains, which feel "like cramps" and sometimes like a dull ache, which will last all day long.  She is also tender in the left breast area and gets numbness in her left hand.  She has also had three spells of "falling", she is not really clear on whether these are syncopal, but they sound like they could be as she sees spots before her eyes.  Twice it happened, when getting up quickly at night and another time in the grocery store.  She suffered no trauma.  She has no remote history of syncope.  Her weight has not changed in the past year.,MEDICATIONS: , Naprosyn, which she takes up to six a day.,ALLERGIES:,  Sulfa.,SOCIAL HISTORY: , She does not smoke or drink.  She is married with two children.,REVIEW OF SYSTEMS:,  Otherwise unremarkable.,PEX:,  BP:  130/70 without orthostatic changes.  PR:  72.  WT:  206 pounds.  She is a healthy young woman.  No JVD.  No carotid bruit.  No thyromegaly.  Cardiac:  Regular rate and rhythm.  There is no significant murmur, gallop, or rub.  Chest:  Mildly tender in the upper pectoral areas bilaterally (breast exam was not performed).  Lungs:  Clear.  Abdomen:  Soft.  Moderately overweight.  Extremities:  No edema and good distal pulses.,EKG: , Normal sinus rhythm, normal EKG.,ECHOCARDIOGRAM (FOR SYNCOPE): , Essentially normal study.,IMPRESSION:,1.  Syncopal spells - These do sound, in fact, to be syncopal.  I suspect it is simple orthostasis/vasovagal, as her EKG and echocardiogram looks good.  I have asked her to drink plenty of fluids and to not to get up suddenly at night.  I think this should take care of the problem.  I would not recommend further workup unless these spells continue, at which time I would recommend a tilt-table study.,2.  Chest pains - Atypical for cardiac etiology, undoubtedly due to musculoskeletal factors from her emotional stressors.  The Naprosyn is not helping that much, I gave her a prescription for Flexeril and instructed her in its use (not to drive after taking it).,RECOMMENDATIONS:,1.  Reassurance that her cardiac checkup looks excellent, which it does.,2.  Drink plenty of fluids and arise slowly from bed.,3.  Flexeril 10 mg q 6 p.r.n.,4.  I have asked her to return should the syncopal spells continue.
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DESCRIPTION: Chest pain, possible syncopal spells.  She has been having multiple cardiovascular complaints including chest pains, which feel like cramps and sometimes like a dull ache, which will last all day long.

consult - history and phy., chest pain, syncopal, echocardiogram, ekg, cardiac etiology, syncopal spells, rhythm, flexeril, cardiac, chest,

This case involves a 31-year-old woman experiencing chest pain and possible syncopal spells. While chest pain and syncope can potentially indicate serious cardiac issues, the tests performed (EKG and echocardiogram) indicate no cardiac pathology. The syncopal episodes are suspected to be vasovagal due to orthostatic changes and stress-related musculoskeletal pain is attributed to her chest pains. The situation is being managed with lifestyle advice and medication for stress relief. Given the medical clearance and low likelihood of immediate serious conditions based on the test results, the stakes are moderate but not urgent, unless symptoms persist or worsen.


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

Medical Specialty: Surgery
Sample Name: Esophagogastroduodenoscopy with Biopsies

PREOPERATIVE DIAGNOSES:,1.  Gastroesophageal reflux disease.,2.  Chronic dyspepsia.,POSTOPERATIVE DIAGNOSES:,1.  Gastroesophageal reflux disease.,2.  Chronic dyspepsia.,3.  Alkaline reflux gastritis.,4.  Gastroparesis.,5.  Probable Billroth II anastomosis.,6.  Status post Whipple's pancreaticoduodenectomy.,PROCEDURE PERFORMED:,  Esophagogastroduodenoscopy with biopsies.,INDICATIONS FOR PROCEDURE: , This is a 55-year-old African-American female who had undergone Whipple's procedure approximately five to six years ago for a benign pancreatic mass.  The patient has pancreatic insufficiency and is already on replacement.  She is currently using Nexium.  She has continued postprandial dyspepsia and reflux symptoms.  To evaluate this, the patient was boarded for EGD.  The patient gave informed consent for the procedure.,GROSS FINDINGS: , At the time of EGD, the patient was found to have alkaline reflux gastritis.  There was no evidence of distal esophagitis.  Gastroparesis was seen as there was retained fluid in the small intestine.  The patient had no evidence of anastomotic obstruction and appeared to have a Billroth II reconstruction by gastric jejunostomy.  Biopsies were taken and further recommendations will follow.,PROCEDURE:  ,The patient was taken to the Endoscopy Suite.  The heart and lungs examination were unremarkable.  The vital signs were monitored and found to be stable throughout the procedure.  The patient's oropharynx was anesthetized with Cetacaine spray.  She was placed in left lateral position.  The patient had the video Olympus GIF gastroscope model inserted per os and was advanced without difficulty through the hypopharynx.  GE junction was in normal position.  There was no evidence of any hiatal hernia.  There was no evidence of distal esophagitis.  The gastric remnant was entered.  It was noted to be inflamed with alkaline reflux gastritis.  The anastomosis was open and patent.  The small intestine was entered.  There was retained fluid material in the stomach and small intestine and _______ gastroparesis.  Biopsies were performed.  Insufflated air was removed with withdrawal of the scope.  The patient's diet will be adjusted to postgastrectomy-type diet.  Biopsies performed.  Diet will be reviewed.  The patient will have an upper GI series performed to rule out more distal type obstruction explaining the retained fluid versus gastroparesis.  Reglan will also be added.  Further recommendations will follow.
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DESCRIPTION: Esophagogastroduodenoscopy with biopsies.  Gastroesophageal reflux disease, chronic dyspepsia, alkaline reflux gastritis, gastroparesis, probable Billroth II anastomosis, and status post Whipple's pancreaticoduodenectomy.

surgery, gastroesophageal reflux disease, chronic dyspepsia, alkaline reflux gastritis, gastroparesis, whipple's pancreaticoduodenectomy, billroth ii anastomosis, gastroesophageal reflux, alkaline reflux, reflux gastritis, gif, esophagogastroduodenoscopy, dyspepsia, gastritis, anastomosis, pancreaticoduodenectomy, biopsies, alkaline, reflux,

The situation involves a medical procedure, Esophagogastroduodenoscopy (EGD), on a patient with complex medical history, including a past Whipple's procedure, which is a major surgery. The findings and outcomes of this procedure can greatly influence the patient's treatment plan and quality of life, especially considering the conditions identified, like alkaline reflux gastritis and gastroparesis, which can be significant if left untreated. However, it is not an immediate life-threatening condition, and the procedure described seems to have been completed without acute complications. Therefore, it's important but not critically urgent.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Orthopedic
Sample Name: Bunionectomy & Metatarsal Osteotomy

PREOPERATIVE DIAGNOSES:,1.  Bunion left foot.,2.  Hammertoe, left second toe.,POSTOPERATIVE DIAGNOSES:,1.  Bunion left foot.,2.  Hammertoe, left second toe.,PROCEDURE PERFORMED:,1.  Bunionectomy, SCARF type, with metatarsal osteotomy and internal screw fixation, left.,2.  Arthroplasty left second toe.,HISTORY:  ,This 39-year-old female presents to ABCD General Hospital with the above chief complaint.  The patient states that she has had bunion for many months.  It has been progressively getting more painful at this time.  The patient attempted conservative treatment including wider shoe gear without long-term relief of symptoms and desires surgical treatment.,PROCEDURE: , An IV was instituted by the Department of Anesthesia in the preop holding area.  The patient was transported to the operating room and placed on the operating table in the supine position with a safety belt across her lap.  Copious amount of Webril were placed around the left ankle followed by a blood pressure cuff.  After adequate sedation was achieved by the Department of Anesthesia, a total of 15 cc of 0.5% Marcaine plain was injected in a Mayo and digital block to the left foot.  The foot was then prepped and draped in the usual sterile orthopedic fashion.  The foot was elevated from the operating table and exsanguinated with an Esmarch bandage.  The pneumatic ankle tourniquet was inflated to 250 mmHg and the foot was lowered to the operating table.  The stockinette was reflected.  The foot was cleansed with wet and dry sponge.  Attention was then directed to the first metatarsophalangeal joint of the left foot.  An incision was created over this area approximately 6 cm in length.  The incision was deepened with a #15 blade.  All vessels encountered were ligated for hemostasis.  The skin and subcutaneous tissue was then dissected from the capsule.  Care was taken to preserve the neurovascular bundle.  Dorsal linear capsular incision was then created.  The capsule was then reflected from the head of the first metatarsal.  Attention was then directed to the first interspace where a lateral release was performed.  A combination of sharp and blunt dissection was performed until the abductor tendons were identified and transected.  A lateral capsulotomy was performed.  Attention was then directed back to the medial eminence where sagittal saw was used to resect the prominent medial eminence.  The incision was then extended proximally with further dissection down to the level of the bone.  Two 0.45 K-wires were then inserted as access guides for the SCARF osteotomy.  A standard SCARF osteotomy was then performed.  The head of the first metatarsal was then translocated laterally in order to reduce the first interspace in the metatarsal angle.  After adequate reduction of the bunion deformity was noted, the bone was temporarily fixated with a 0.45 K-wire.  A 3.0 x 12 mm screw was then inserted in the standard AO fashion with compression noted.  A second 3.0 x 14 mm screw was also inserted with tight compression noted.  The remaining prominent medial eminence medially was then resected with a sagittal saw.  Reciprocating rasps were then used to smooth any sharp bony edges.  The temporary fixation wires were then removed.  The screws were again checked for tightness, which was noted.  Attention was directed to the medial capsule where a medial capsulorrhaphy was performed.  A straight stat was used to assist in removing a portion of the capsule.  The capsule was then reapproximated with #2-0 Vicryl medially.  Dorsal capsule was then reapproximated with #3-0 Vicryl in a running fashion.  The subcutaneous closure was performed with #4-0 Vicryl followed by running subcuticular stitch with #5-0 Vicryl.  The skin was then closed with #4-0 nylon in a horizontal mattress type fashion.,Attention was then directed to the left second toe.  A dorsal linear incision was then created over the proximal phalangeal joint of the left second toe.  The incision was deepened with a #15 blade and the skin and subcutaneous tissue was dissected off the capsule to be aligned laterally.  An incision was made on either side of the extensor digitorum longus tendon.  A curved mosquito stat was then used to reflex the tendon laterally.  The joint was identified and the medial collateral ligamentous attachments were resected off the head of the proximal phalanx.  A sagittal saw was then used to resect the head of the proximal head.  The bone was then rolled and the lateral collateral attachments were transected and the bone was removed in toto.  The extensor digitorum longus tendon was inspected and noted to be intact.  Any sharp edges were then smoothed with reciprocating rasp.  The area was then flushed with copious amounts of sterile saline.  The skin was then reapproximated with #4-0 nylon.  Dressings consisted of Owen silk, 4x4s, Kling, Kerlix, and Coban.  Pneumatic ankle tourniquet was released and an immediate hyperemic flush was noted to all five digits of the left foot.  The patient tolerated the above procedure and anesthesia well without complications.  The patient was transported to PACU with vital signs stable and vascular status intact to the left foot.  The patient is to follow up with Dr. X in his clinic as directed.
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DESCRIPTION: Bunionectomy, SCARF type, with metatarsal osteotomy and internal screw fixation, left and arthroplasty left second toe.  Bunion left foot and hammertoe, left second toe.

orthopedic, hammertoe, osteotomy, internal screw fixation, scarf type, extensor digitorum, metatarsal osteotomy, foot, toe, metatarsal, bunionectomy,

The situation described is a surgical procedure for correcting a bunion and hammertoe, which involves careful execution by the surgical team, use of anesthesia, and postoperative care. While surgeries inherently have risks, this type of procedure is generally considered routine and standard in orthopedic practices. The report indicates the patient tolerated the procedure well and no complications arose during or immediately after surgery. This suggests the situation is under control without any immediate high-stakes issues.


Medical Specialty: Orthopedic
Sample Name: ORIF - Discharge Summary

ADMISSION DIAGNOSIS: , Right tibial plateau fracture.,DISCHARGE DIAGNOSES: , Right tibial plateau fracture and also medial meniscus tear on the right side.,PROCEDURES PERFORMED:,  Open reduction and internal fixation (ORIF) of right Schatzker III tibial plateau fracture with partial medial meniscectomy.,CONSULTATIONS: , To rehab, Dr. X and to Internal Medicine for management of multiple medical problems including hypothyroid, diabetes mellitus type 2, bronchitis, and congestive heart failure.,HOSPITAL COURSE: , The patient was admitted and consented for operation, and taken to the operating room for open reduction and internal fixation of right Schatzker III tibial plateau fracture and partial medial meniscectomy performed without incidence.  The patient seemed to be recovering well.  The patient spent the next several days on the floor, nonweightbearing with CPM machine in place, developed a brief period of dyspnea, which seems to have resolved and may have been a combination of bronchitis, thick secretions, and fluid overload.  The patient was given nebulizer treatment and Lasix increased the same to resolve the problem.  The patient was comfortable, stabilized, breathing well.  On day #12, was transferred to ABCD.,DISCHARGE INSTRUCTIONS: , The patient is to be transferred to ABCD after open reduction and internal fixation of right tibial plateau fracture and partial medial meniscectomy.,DIET:,  Regular.,ACTIVITY AND LIMITATIONS: , Nonweightbearing to the right lower extremity.  The patient is to continue CPM machine while in bed along with antiembolic stockings.  The patient will require nursing, physical therapy, occupational therapy, and social work consults.,DISCHARGE MEDICATIONS: , Resume home medications, but increase Lasix to 80 mg every morning, Lovenox 30 mg subcu daily x2 weeks, Vicodin 5/500 mg one to two every four to six hours p.r.n. pain, Combivent nebulizer every four hours while awake for difficulty breathing, Zithromax one week 250 mg daily, and guaifenesin long-acting one twice a day b.i.d.,FOLLOWUP: , Follow up with Dr. Y in 7 to 10 days in office.,CONDITION ON DISCHARGE:,  Stable.
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DESCRIPTION: Open reduction and internal fixation (ORIF) of right Schatzker III tibial plateau fracture with partial medial meniscectomy.

orthopedic, open reduction, internal fixation, schatzker iii tibial plateau fracture, meniscectomy, tibial plateau fracture, orif, schatzker, fixation, reduction, tibial, fracture, plateau,

The case involves a patient who underwent a significant orthopedic surgical procedure, specifically an open reduction and internal fixation of a tibial plateau fracture, along with a partial meniscectomy. Although the procedure itself might be routine for orthopedic surgeons, the patient's medical history is complex. The patient suffers from multiple serious conditions such as diabetes, hypothyroidism, bronchitis, and congestive heart failure, which complicates the post-operative care and increases the risk for complications. These factors elevate the stakes of the situation, as mismanagement could lead to severe consequences like infection, deep vein thrombosis, or exacerbation of heart failure. However, the patient is currently stable, which reduces immediate high stakes, but the requirement for careful follow-up and management keeps it at a moderate to high level of concern.


Medical Specialty: Consult - History and Phy.
Sample Name: Barium Swallow Study Evaluation

HISTORY: , The patient is a 71-year-old female, who was referred for an outpatient modified barium swallow study to objectively evaluate her swallowing function and safety.  The patient complained of globus sensation high in her throat particularly with solid foods and with pills.  She denied history of coughing and chocking with meals.  The patient's complete medical history is unknown to me at this time.  The patient was cooperative and compliant throughout this evaluation.,STUDY:,  Modified barium swallow study was performed in the Radiology Suite in cooperation with Dr. X. The patient was seated upright at a 90-degree angle in a video imaging chair.  To evaluate her swallowing function and safety, she was administered graduated amounts of food and liquid mixed with barium in the form of thin liquids (teaspoon x3. cup sip x4); thickened liquid (cup sip x3); puree consistency (teaspoon x3); and solid consistency (1/4 cracker x1).  The patient was given 2 additional cup sips of thin liquid following the puree and solid food presentation.,ORAL STAGE:  ,The patient had no difficulty with bolus control and transport.  No spillage out lips.  The patient appears to have pocketing __________ particularly with puree and solid food between her right faucial pillars.  The patient did state that she had her tonsil taken out as a child and appears to be a diverticulum located in this state.  Further evaluation by an ENT is highly recommended based on the residual and pooling that occurred during this evaluation.  We were not able to clear out the residual with alternating cup sips and thin liquid.,PHARYNGEAL STAGE:  ,No aspiration or penetration occurred during this evaluation.  The patient's hyolaryngeal elevation and anterior movements are within the functional limits.  Epiglottic inversion is within functional limits.  She had no residual or pooling in the pharynx after the swallow.,CERVICAL ESOPHAGEAL STAGE:  ,The patient's upper esophageal sphincter opening is well coordinated with swallow and readily accepted the bolus.,DIAGNOSTIC IMPRESSION:  ,The patient had no aspiration or penetration occurred during this evaluation.  She does appear to have a diverticulum in the area between her right faucial pillars.  Additional evaluation is needed by an ENT physician.,PLAN:  ,Based on this evaluation, the following is recommended:,1.  The patient's diet should consist regular consistency food with thin liquids.  She needs to take small bites and small sips to help decrease her risk of aspiration and penetration as well as reflux.,2.  The patient should be referred to an otolaryngologist for further evaluation of her oral cavity particularly the area between her faucial pillars.,The above recommendations and results of the evaluation were discussed with the patient as well as her daughter and both responded appropriately.,Thank you for the opportunity to be required the patient's medical care.  She is not in need of skilled speech therapy and is discharged from my services.
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DESCRIPTION: Modified Barium swallow study evaluation to objectively evaluate swallowing function and safety.  The patient complained of globus sensation high in her throat particularly with solid foods and with pills.  She denied history of coughing and chocking with meals.

consult - history and phy., globus sensation, oral stage, pharyngeal stage, cervical esophageal stage, consistency, otolaryngologist, barium swallow study evaluation, faucial pillars, swallow study, solid foods, evaluation, liquid, barium, oral, swallow, foods,

The situation involves a medical evaluation of a patient's swallowing function using a modified barium swallow study, which is significant in diagnosing potential swallowing disorders. While the evaluation did not show aspiration or penetration, it did identify a diverticulum requiring further investigation by an ENT specialist. Such an issue, if not assessed and managed appropriately, could impact the patient's quality of life and safety during eating. However, immediate life-threatening risks were not identified during the evaluation. Therefore, while important, the situation is not extremely high-stakes, as no urgent or acute intervention is immediately required.


Medical Specialty: Surgery
Sample Name: Carotid Endarterectomy

PREOPERATIVE DIAGNOSES:,1.  Right carotid stenosis.,2.  Prior cerebrovascular accident.,POSTOPERATIVE DIAGNOSES:,1.  Right carotid stenosis.,2.  Prior cerebrovascular accident.,PROCEDURE PERFORMED:  ,Right carotid endarterectomy with patch angioplasty.,ESTIMATED BLOOD LOSS:  ,250 cc.,OPERATIVE FINDINGS: , The common and internal carotid arteries were opened.  A high-grade narrowing was present at the proximal internal carotid and this tapered well to a slightly small diameter internal carotid.  This was repaired with a Dacron patch and the patient tolerated this well under regional anesthetic without need for shunting.,PROCEDURE:  ,The patient was taken to the operating room, placed in supine position, prepped and draped in the usual sterile manner with Betadine solution.  Longitudinal incisions were made along the anterior border of the sternocleidomastoid, carried down through subcutaneous fat and fascia.  Hemostasis was obtained with electrocautery.  The platysmal muscle was divided.  The carotid sheath was identified and opened.  The vagus nerve, ansa cervicalis, and hypoglossal nerves were identified and avoided.  The common internal and external carotids were then freed from the surrounding tissue.  At this point, 10,000 units of aqueous heparin were administered and allowed to take effect.  The external and common carotids were then clamped.  The patient's neurological status was evaluated and found to be unchanged from preoperative levels.,Once sufficient time had lapsed, we proceeded with the procedure.  The carotid bulb was opened with a #11 blade and extended with Potts scissors through the very tight lesion into normal internal carotid.  The plaque was then sharply excised proximally and an eversion endarterectomy was performed successfully at the external.  The plaque tapered nicely on the internal and no tacking sutures were necessary.  Heparinized saline was injected and no evidence of flapping or other debris was noted.  The remaining carotid was examined under magnification, which showed no debris of flaps present.  At this point, a Dacron patch was brought on to the field, cut to appropriate length and size, and anastomosed to the artery using #6-0 Prolene in a running fashion.  Prior to the time of last stitch, the internal carotid was back-bled through this.  The last stitch was tied.  Hemostasis was excellent.  The internal was again gently occluded while flow was restored to the common and external carotids for several moments and then flow was restored to the entire system.  At this point, a total of 50 mg of Protamine was administered and allowed to take effect.  Hemostasis was excellent.  The wound was irrigated with antibiotic solution and closed in layers using #3-0 Vicryl and #4-0 undyed Vicryl.  The patient was then taken to the recovery room in satisfactory condition after tolerating the procedure well.  Sponge, needles, and instrument count were correct.  Estimated blood loss was 250 cc.
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DESCRIPTION: Right carotid stenosis and prior cerebrovascular accident. Right carotid endarterectomy with patch angioplasty.

surgery, carotid stenosis, cerebrovascular, platysmal, dacron patch, carotid endarterectomy, cerebrovascular accident, internal carotid, carotid, stenosis, carotids, endarterectomy

A carotid endarterectomy is a surgical procedure performed to reduce the risk of stroke by correcting stenosis (narrowing) in the common carotid artery. This is considered a high-stakes procedure due to several factors: it involves critical structures (carotid arteries) that supply blood to the brain, carries risks of complications such as stroke, heart attack, or death, and requires careful surgical technique to avoid damage to surrounding nerves and tissues. Additionally, the patient has a history of cerebrovascular accident, increasing the importance of restoring proper blood flow. This type of surgery generally demands high skill and precision and has significant potential impacts on the patient's health outcomes. However, the procedure here was described as having been performed successfully without shunting or complications, and the patient tolerated it well, which slightly mitigates the immediate stakes involved.


Medical Specialty: Neurology
Sample Name: SOAP - Numbness & Tingling

SUBJECTIVE: , This patient presents to the office today because of some problems with her right hand.  It has been going tingling and getting numb periodically over several weeks.  She just recently moved her keyboard down at work.  She is hoping that will help.  She is worried about carpal tunnel.  She does a lot of repetitive type activities.  It is worse at night.  If she sleeps on it a certain way, she will wake up and it will be tingling then she can usually shake out the tingling, but nonetheless it is very bothersome for her.  It involves mostly the middle finger, although, she says it also involves the first and second digits on the right hand.  She has some pain in her thumb as well.  She thinks that could be arthritis.,OBJECTIVE: , Weight 213.2 pounds, blood pressure 142/84, pulse 92, respirations 16.  General:  The patient is nontoxic and in no acute distress.  Musculoskeletal:  The right hand was examined.  It appears to be within normal limits and the appearance is similar to the left hand.  She has good and equal grip strength noted bilaterally.  She has negative Tinel's bilaterally.  She has a positive Phalen's test.  The fingers on the right hand are neurovascularly intact with a normal capillary refill.,ASSESSMENT:  ,Numbness and tingling in the right upper extremity, intermittent and related to the positioning of the wrist.  I suspect carpal tunnel syndrome.,PLAN:  ,The patient is going to use Anaprox double strength one pill every 12 hours with food as well as a cock-up wrist splint.  We are going to try this for two weeks and if the condition is still present, then we are going to proceed with EMG test at that time.  She is going to let me know.  While she is here, I am going to also get her the blood test she needs for her diabetes.  I am noting that her blood pressure is elevated, but improved from the last visit.  I also noticed that she has lost a lot of weight.  She is working on diet and exercise and she is doing a great job.  Right now for the blood pressure we are going to continue to observe as she carries forward additional measures in her diet and exercise to lose more weight and I expect the blood pressure will continue to improve.
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DESCRIPTION: Numbness and tingling in the right upper extremity, intermittent and related to the positioning of the wrist.  Carpal tunnel syndrome suspected.

neurology, tinel's, phalen's, positioning of the wrist, numbness and tingling, carpal tunnel syndrome, carpal tunnel, numbness, tingling

The situation involves a patient experiencing numbness and tingling in the right hand, suggesting potential carpal tunnel syndrome. While this is a concerning condition for the patient and requires medical attention, it is a common issue that typically has non-invasive treatment options. The immediate approach involves medication and wrist splinting, with further investigation planned only if symptoms persist. There are no immediate life-threatening concerns or complex interventions required, making this situation not critically high-stakes.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: COPD & Bronchitis - Discharge Summary

DIAGNOSIS AT ADMISSION:,  Chronic obstructive pulmonary disease (COPD) exacerbation and acute bronchitis.,DIAGNOSES AT DISCHARGE,1.  Chronic obstructive pulmonary disease exacerbation and acute bronchitis.,2.  Congestive heart failure.,3.  Atherosclerotic cardiovascular disease.,4.  Mild senile-type dementia.,5.  Hypothyroidism.,6.  Chronic oxygen dependent.,7.  Do not resuscitate/do not intubate.,HOSPITAL COURSE: , The patient was admitted from the office by Dr. X.  She was placed on the usual medications that included Synthroid 0.05 mg a day, enalapril 5 mg a day, Imdur 30 mg a day, Lanoxin 0.125 mg a day, aspirin 81 mg a day, albuterol and Atrovent nebulizers q.4 h., potassium chloride 10 mEq 2 tablets per day, Lasix 40 mg a day, Humibid L.A.  600 mg b.i.d.  She was placed on oral Levaquin after a load of 500 mg and 250 mg a day.  She was given oxygen, encouraged to eat, and suctioned as needed.,Laboratory data included a urinalysis that had 0-2 WBCs per high power field and urine culture was negative, blood cultures x2 were negative, TSH was 1.7, and chem-7, sodium 134, potassium 4.4, chloride 93, CO2 34, glucose 105, BUN 17, creatinine 0.9, and calcium 9.1.  Digoxin was 1.3.  White blood cell count was 6100 with a normal differential, H&H 37.4/12.1, platelets 335,000.  Chest x-ray was thought to have prominent interstitial lung changes without acute infiltrate.  There is a question if there is mild fluid overload.,The patient improved with the above regimen.  By discharge, her lungs fell back to her baseline.  She had no significant shortness of breath.  Her O2 saturations were stable.  Her vital signs were stable.,She is discharged home to follow up with me in a week and a half.,Her daughter has been spoken to by phone and she will notify me if she worsens or has problems.,PROGNOSIS:  ,Guarded.
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DESCRIPTION: Chronic obstructive pulmonary disease (COPD) exacerbation and acute bronchitis.

cardiovascular / pulmonary, chronic obstructive pulmonary disease exacerbation, chronic obstructive pulmonary disease, pulmonary, copd, discharge, bronchitis,

The discharge summary describes a complex clinical scenario with multiple significant diagnoses, including COPD exacerbation, acute bronchitis, congestive heart failure, and atherosclerotic cardiovascular disease. The patient's condition requires careful medical management and follow-up, especially considering the presence of comorbidities like dementia and the chronic use of oxygen. The 'Do not resuscitate/do not intubate' directive indicates that discussions around end-of-life care have likely occurred, highlighting the serious nature of the patient's health. The prognosis is described as 'guarded,' suggesting uncertainty about the patient's long-term health outcomes. Overall, while the immediate situation at the time of discharge may be stable, the potential for rapid deterioration makes this a high-stakes situation.


Medical Specialty: Consult - History and Phy.
Sample Name: Wound Care Consult

TYPE OF CONSULTATION:,  Wound care consult.,HISTORY OF PRESENT ILLNESS:,  The patient is a 62-year-old woman with a past medical history significant for prior ileojejunal bypass for weight loss (1980) and then subsequent gastric banding (2002 Dr. X) who was transferred to this facility following a complicated surgical and postoperative course after takedown of the prior gastroplasty and bypass (07/08/2008, Dr. Y).  The patient has been followed by Cardiothoracic Surgery (Dr. Z) as an outpatient.  She had a history of daily postprandial vomiting, regurgitation, and heartburn.  She underwent a preop assessment of her GERD and postprandial vomiting including nuclear gastric emptying studies, which showed increased esophageal retention with normal gastric emptying.  Preoperative barium swallow demonstrated moderated esophageal dysmotility with incomplete emptying and a small hiatal hernia.  It was recommended that she undergo an exploratory laparotomy and possible redo fundoplication and possible gastrectomy.  She had already undergone multiple EGDs with dilatations without success.  She continued to have abdominal discomfort.,On 07/07/2008, she was admitted to hospital.  She underwent an exploratory laparotomy with esophagogastrectomy with esophagogastric anastomosis and Dor fundoplication, repair of hiatal hernia, small bowel resection x2 with primary anastomosis, extensive lysis of adhesions, insertion of a red-rubber J tube, and esophagogastroduodenoscopy.  She also had her ileojejunal bypass reversed.  Postoperatively, she was able to be extubated.  She was started on TPN, given the risk of not being able to tolerate enteral nutrition.  Her operative note confirmed that the stomach pouch was enlarged with outlet obstruction where the band was.  There was 2 hours of extensive lysis of adhesions.  It took 2 hours to identify the colon.  A defect was repaired in the transverse colon.  The bypass segment of the anastomosis was seen between the proximal jejunum and the distal ileum, which was divided and the proximal jejunum was reconnected to the atretic blind limb of the small bowel.  A red feeding tube was placed proximal to the anastomosis then tended to cross the anastomosis into the distal atretic small bowel for enteral feeds.  The hiatal hernia was repaired as noted.  The obstructed proximal gastric segment was resected.  An anastomosis was made between the proximal intestine and the stomach and distal esophagus with Dor fundoplication.  Omentectomy was performed due to devascularization.  The wound was able to be closed with staples.,Postoperatively, the patient was started on IV antibiotics.  She was able to be extubated.  However, on 07/14/2008, she coded with shortness of breath and chest pain.  She had respiratory failure, required endotracheal intubation and ICU management.  CT scan of the abdomen and the pelvis confirmed that she had an anastomotic leak.  Sputum cultures were positive ESBL Klebsiella.  Blood cultures were negative.  She was managed closely for sepsis with an elevated white cell count.  She was also febrile.  Her chest x-ray also showed left lower lobe consolidation.  She had scattered contrast material in the anterior abdomen and left upper quadrant due to the anastomotic leak.  Her antibiotics were adjusted.  Of note, the patient did have a JP drain placed out to the surface during her initial surgery.  Followup CT scan on 07/16/2008 confirmed the anastomosis as the likely site of a fistula, as there was continued extraluminal enteric contrast seen within anterior abdomen just beneath the peritoneum as well as the left upper quadrant adjacent to the spleen.  No enteric contrast was seen surrounding the patient's known GE junction leak.  A JP drain was noted at the posterior aspect of the fundoplication.  There was only a small amount of pelvic fluid.  Follow up scan again on 07/25/2008 showed no abscess formation.  On 08/05/2008, she did underwent an advancement of the #14 French red-rubber catheter feeding tube distal to the dehiscence of fistula into the distal small bowel.  At the beginning of the procedure, the catheter did appear to traverse through an anastomotic suture line in the wound dehiscence.  At some point during her course, the patient did undergo a second operative procedure, but I do not have any operative note at this time.  She subsequently was left with a large open abdominal defect, which was being managed by the wound care nurses, which at the time of her transfer to this facility was being managed with a "wound manager system." to low-continuous wall suction.  She was also transferred on tube feedings via the red rubber catheter 20 mL per hour.  She is only to have her tube feeds increased by 10 mL a week to ensure tolerance.  During her course, she was started on TPN.  She was transferred on TPN here.,At the time of her transfer, the patient was no longer on IV antibiotics.  She is on Fragmin for DVT prophylaxis.  During her course, she did have to undergo a tracheostomy.  This has subsequently been removed and this site is healing.  The tracheostomy was removed on 08/06/2008, I believe.  At the time of her tracheostomy (on 07/22/2008), the patient also underwent a flexible bronchoscopy, which showed some secretions in the left airway (right was clear), which did not appear to be purulent.  Of note also, pathology of her partial stomach resection showed Helicobacter pylori gastritis.  There were no other significant abnormalities noted in the small intestine or omentum.  On 08/11/2008, the patient was transferred to HealthSouth Monroeville LTAC for continued medical management, wound care, and rehab therapies.1,PAST MEDICAL HISTORY:  ,History of diabetes with peripheral neuropathy - on Lyrica and Cymbalta preoperatively.  History of hypothyroidism, history of B12 deficiency related to prior gastric surgeries, history of osteoarthritis, history of valvular disease (no details available), and cardiac arrhythmias.,PAST SURGICAL HISTORY:,  Status post bilateral total knee replacements, status post right rotator cuff repair, status post sigmoid colectomy - no further details available, status post right breast lumpectomy for benign lesion, history of bladder repair, status post hysterectomy/tonsillectomy/appendectomy, history of lumbar spinal fusion - no further details available.  History of MRSA in knees (previous surgery).,ALLERGIES:,  MULTIPLE INCLUDING TETRACYCLINE, ERYTHROMYCIN, MORPHINE, SULFA DRUGS, BETADINE, ADHESIVE TAPES, AND BANDAGE.,SOCIAL HISTORY:,  Prior to admission, the patient lived alone in a one storied dwelling.  She does have some equipment at home including a powered wheelchair, which she uses for longer distance.  She does have some ambulatory devices also.  She used to smoke, but quit about 10 years ago.  She smoked 1 to 2 packs a day from age 18 to 54.  She does not smoke.,FAMILY HISTORY:,  Remarkable for cardiac disease with early death of her father at age 43 and mother had Alzheimer.,REVIEW OF SYSTEMS: , According to her notes, the patient's weight 07/10/2008 was 256 pounds.  She has a BMI of 44 indicating morbid obesity.  She had had a significant weight loss in the 6 months prior to this of 7%.  As noted, she is on TPN and enteral feeds.  Her prealbumin level noted on 07/10/2008 was low at 7.  Prior to admission, the patient ate a regular diet, but had most likely weight loss and inadequate intake due to her chronic postprandial vomiting and esophageal dysmotility.  She is currently NPO with NG to suction.  The patient has no complaints of abdominal pain or discomfort at the time of this exam.  She was awake and alert.  MRSA screen on 07/14/2008 was negative.,PHYSICAL EXAMINATION:,General:  The patient is a morbidly obese woman, who is in no acute distress at the time of this exam.  She is lying comfortably on a low air loss mattress.  She had just been assisted with cleaning up and had no complaints of pain or discomfort.,Vital Signs:  Temperature is 98.9, pulse is 95, blood pressure is 123/69, and weight is 239 pounds.,HEENT:  Normocephalic/atraumatic.  Extraocular muscles intact.  Her mentation is good.,Neck:  Stout.  There is good range of motion.,Cor:  Regular rate and rhythm.  No murmurs appreciated.,Lungs:  Fairly clear anteriorly.,Abdomen:  Remarkable for a large open abdominal wound with a collection system in place covering the entire wound in midline.  There is a JP drain and a red rubber catheter present.  At present, the wound manager system is somewhat collapsed.  She had just been on her side.  It is connected to low continuous wall suction and removing fluid.,Musculoskeletal:  There is PICC line present in the right upper extremity.  No significant pedal edema.  Bilateral knee scars from prior surgeries.,Skin:  Reported intact at this time (not seen by me).,Neurological:  Cranial nerves II through XII grossly intact.  She is able to answer questions appropriately.  She is able to raise both arms over head.  She is able to raise her legs, but does need assistance.  She has fair bed mobility and requires much assistance for any turning.  Gait and transfers not tested.,SUMMARY: , In summary, the patient is a 62-year-old woman with a remote history of ileojejunal bypass followed by gastric banding to facilitate weight loss.  However, she subsequently developed reflux associated with postprandial vomiting, which was found to be secondary to esophageal retention.  On 07/08/2008, she underwent exploratory laparotomy with esophagogastrectomy with esophagogastric anastomosis and Dor fundoplication, hiatal hernia repair, small bowel resection, and lysis of adhesions.  She has had a fairly rocky postoperative course and has subsequently underwent some type of re-exploration after she was noted to have enteric contents draining from her JP drain with confirmed anastomotic leak.  She has undergone placement on an NG tube.  At present, she is on enteral feeds as well as TPN.  During all these, she also coded and had respiratory failure, requiring vent management, but this has improved.  Her trach has been removed and this site is healing.  From the wound standpoint, her largest problem at this point is the abdominal wound, which is open.  A wound manager system is currently in place, which is connected to low intermittent wall suction for drainage of the enteral contents still present. At present, the drainage is quite yellow in appearance.  She has no significant complaints of pain at this time.  At some point in her notes, there was mention of a negative pressure wound therapy being used to this wound, but this cannot be confirmed at this time.  I will plan to contact Dr. Z's office to see whether or not they wanted to resume a wound VAC system to this wound.  For now, we will continue with wound manager system.  We will need to keep track of in's and out's of drainage from this site.  Her fluid status will need to be monitored.  In an attempt to get her mobilized, we will need extra care to be sure that this wound dressing/management system stays in place.  She is eager and motivated to get mobilized.  We will plan to ask Plastic (Dr. A) to be involved in following this wound also.  Again, I will plan to call the surgeon's office for further directions.  She is to follow up with Dr. Z in 2 weeks.,Later in afternoon, I was able to reach Dr. Z's office.  I was called back by one of his nurses, who advised me that a wound VAC (negative pressure wound therapy) was not to be used on this wound.  They are using the wound manager system.  She did report that the confusion came about with the inability during her discharge summary dictation that she was only able to cite a "wound VAC" when describing the system that was in place on the patient.  She was using a formatted discharge summary program.  At present, the patient has had some leakage from the system.  According to my discussion with our wound care coordinator at this time, this system has been removed, with leakage repaired, and replaced with another wound manager system with suctioning continuing.  Pictures were also taken of the wound bed.  There were several staples apparently in place.  I was not present at the time that this system had to be changed.
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DESCRIPTION: A woman with a remote history of ileojejunal bypass followed by gastric banding to facilitate weight loss.

The described medical situation involves a patient with a complex medical and surgical history, including severe complications such as an anastomotic leak after surgery, which required intensive care and led to respiratory failure. Additionally, the patient has a large open abdominal wound requiring specialized wound care management. This situation is high-stakes due to the potential life-threatening nature of anastomotic leaks, the complexity of managing the patient’s nutritional needs via TPN and enteral feeds, and the need for careful wound care to prevent further complications. The involvement of multiple medical specialties and the need for close monitoring further underscore the high-stakes nature of this case.


Medical Specialty: Pediatrics - Neonatal
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 the discharge summary of an 11-year-old boy initially suspected of having mastoiditis, a potentially serious condition. However, mastoiditis was ruled out. The actual condition, right acute otitis media, while uncomfortable, is a more common and less severe condition than mastoiditis. The child has shown improvement in symptoms, and appropriate follow-up care has been arranged. This scenario is typical in a clinical setting and not considered high-stakes as immediate life-threatening risk has been managed and mitigated.


Medical Specialty: Discharge Summary
Sample Name: Psychiatric Discharge Summary - 2

DISCHARGE SUMMARY,SUMMARY OF TREATMENT PLANNING:,  This discharge is at the family's request.,IDENTIFIED PROBLEMS/OUTCOMES:,1.
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DESCRIPTION: Discharge summary of a patient with depression and high risk behavior.

Discharge summaries, especially those related to psychiatric conditions such as depression with high-risk behavior, are inherently high-stakes due to the potential impact on the patient's health and well-being post-discharge. These documents contain crucial information about treatment plans, risk assessments, and follow-up care necessary to prevent adverse outcomes.


Medical Specialty: Neurosurgery
Sample Name: Lumbar Puncture - 1

PROCEDURE: , Lumbar puncture with moderate sedation.,INDICATION: , The patient is a 2-year, 2-month-old little girl who presented to the hospital with severe anemia, hemoglobin 5.8, elevated total bilirubin consistent with hemolysis and weak positive direct Coombs test.  She was transfused with packed red blood cells.  Her hemolysis seemed to slow down.  She also on presentation had indications of urinary tract infection with urinalysis significant for 2+ leukocytes, positive nitrites, 3+ protein, 3+ blood, 25 to 100 white cells, 10 to 25 bacteria, 10 to 25 epithelial cells on clean catch specimen.  Culture subsequently grew out no organisms; however, the child had been pretreated with amoxicillin about x3 doses prior to presentation to the hospital.  She had a blood culture, which was also negative.  She was empirically started on presentation with the cefotaxime intravenously.  Her white count on presentation was significantly elevated at 20,800, subsequently increased to 24.7 and then decreased to 16.6 while on antibiotics.  After antibiotics were discontinued, she increased over the next 2 days to an elevated white count of 31,000 with significant bandemia, metamyelocytes and myelocytes present.  She also had three episodes of vomiting and thus she is being taken to the procedure room today for a lumbar puncture to rule out meningitis that may being inadvertently treated in treating her UTI.,I discussed with The patient's parents prior to the procedure the lumbar puncture and moderate sedation procedures.  The risks, benefits, alternatives, complications including, but not limited to bleeding, infection, respiratory depression.  Questions were answered to their satisfaction.  They would like to proceed.,PROCEDURE IN DETAIL: , After "time out" procedure was obtained, the child was given appropriate monitoring equipment including appropriate vital signs were obtained.  She was then given Versed 1 mg intravenously by myself.  She subsequently became sleepy, the respiratory monitors, end-tidal, cardiopulmonary and pulse oximetry were applied.  She was then given 20 mcg of fentanyl intravenously by myself.  She was placed in the left lateral decubitus position.  Dr. X cleansed the patient's back in a normal sterile fashion with Betadine solution.  She inserted a 22-gauge x 1.5-inch spinal needle in the patient's L3-L4 interspace that was carefully identified under my direct supervision.  Clear fluid was not obtained initially, needle was withdrawn intact.  The patient was slightly repositioned by the nurse and Dr. X reinserted the needle in the L3-L4 interspace position, the needle was able to obtain clear fluid, approximately 3 mL was obtained.  The stylette was replaced and the needle was withdrawn intact and bandage was applied.  Betadine solution was cleansed from the patient's back.,During the procedure, there were no untoward complications, the end-tidal CO2, pulse oximetry, and other vitals remained stable.  Of note, EMLA cream had also been applied prior procedure, this was removed prior to cleansing of the back.,Fluid will be sent for a routine cell count, Gram stain culture, protein, and glucose.,DISPOSITION: , The child returned to room on the medical floor in satisfactory condition.
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DESCRIPTION: Lumbar puncture with moderate sedation.

Lumbar puncture with moderate sedation.

neurosurgery, moderate sedation, lumbar puncture, needle, lumbar,

The situation involves a lumbar puncture procedure on a young child with multiple underlying medical concerns including a suspected meningitis and severe anemia. The procedure has potential risks such as bleeding, infection, and respiratory depression. Additionally, the child requires sedation which adds further complexity and risk. Overall, this medical procedure is high-stakes due to the potential complications and the critical condition of the patient.


Medical Specialty: Urology
Sample Name: Inguinal Herniorrhaphy

PROCEDURE PERFORMED: , Inguinal herniorrhaphy.,PROCEDURE: , After informed consent was obtained, the patient was brought to the operative suite and placed supine on the operating table.  General endotracheal anesthesia was induced without incident.  The patient was prepped and draped in the usual sterile manner.,A standard inguinal incision was made and dissection was carried down to the external oblique aponeurosis using a combination of Metzenbaum scissors and Bovie electrocautery.  The external oblique aponeurosis was cleared of overlying adherent tissue, and the external ring was delineated.  The external oblique was then incised with a scalpel, and this incision was carried out to the external ring using Metzenbaum scissors.  Having exposed the inguinal canal, the cord structures were separated from the canal using blunt dissection, and a Penrose drain was placed around the cord structures at the level of the pubic tubercle.  This Penrose drain was then used to retract the cord structures as needed.  Adherent cremasteric muscle was dissected free from the cord using Bovie electrocautery.,The cord was then explored using a combination of sharp and blunt dissection, and the sac was found anteromedially to the cord structures.  The sac was dissected free from the cord structures using a combination of blunt dissection and Bovie electrocautery.  Once preperitoneal fat was encountered, the dissection stopped and the sac was suture ligated at the level of the preperitoneal fat using a 2-0 silk suture ligature.  The sac was excised and went to  Pathology.  The ends of the suture were then cut and the stump retracted back into the abdomen.,The Penrose drain was removed.  The wound was then irrigated using sterile saline, and hemostasis was obtained using Bovie electrocautery.  The incision in the external oblique was approximated using a 3-0 Vicryl in a running fashion, thus reforming the external ring.  The skin incision was approximated with 4-0 Vicryl in a subcuticular fashion.  The skin was prepped and draped with benzoin, and Steri-Strips were applied.  A dressing consisting of a 2 x 2 and OpSite was then applied.  All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently extubated and taken to the recovery room in good and stable condition.
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DESCRIPTION: Inguinal herniorrhaphy.  A standard inguinal incision was made and dissection was carried down to the external oblique aponeurosis using a combination of Metzenbaum scissors and Bovie electrocautery.

urology, inguinal canal, cremasteric muscle, pubic tubercl, inguinal herniorrhaphy, blunt dissection, penrose drain, bovie electrocautery, cord structures, inguinal, electrocautery, cord

The document describes a straightforward inguinal herniorrhaphy, a common surgical procedure aimed at repairing an inguinal hernia. The procedure seems to have gone smoothly without any noted complications. The patient was reported to be in good and stable condition post-operation. Inguinal herniorrhaphy is a routine and standardized surgery with minimal risk involved when performed by trained professionals. Although all surgeries carry inherent risks, this is a low-stakes situation given the routine nature of the procedure, the lack of complications, and the stable condition of the patient post-operatively.


Medical Specialty: Consult - History and Phy.
Sample Name: Iliopsoas Hematoma - 1

CC: ,Gait difficulty.,HX: ,This 59 y/o RHF was admitted with complaint of gait difficulty. The evening prior to admission she noted sudden onset of LUE and LLE weakness. She felt she favored her right leg, but did not fall when walking. She denied any associated dysarthria, facial weakness, chest pain, SOB, visual change, HA, nausea or vomiting.,PMH:, tonsillectomy, adenoidectomy, skull fx 1954, HTN, HA.,MEDS: ,none on day of exam.,SHX: ,editorial assistant at newspaper, 40pk-yr Tobacco, no ETOH/Drugs.,FHX: ,noncontributory,ADMIT EXAM: ,P95 R20, T36.6, BP169/104,MS: A&O to person, place and time. Speech fluent and without dysarthria, Naming-comprehension-reading intact. Euthymic with appropriate affect.,CN: Pupils 4/4 decreasing to 2/2 on exposure to light, Fundi flat, VFFTC, EOMI, Face symmetric with intact sensation, Gag-shrug-corneal reflexes intact, Tongue ML with full ROM,Motor: Full strength throughout right side. Mildly decreased left grip and left extensor hallucis longus. Biceps/Triceps/Wrist flexors and extensor were full strength on left. However she demonstrated mild LUE pronator drift and had difficulty standing on her LLE despite full strength on bench testing of the LLE.,Sensory: No deficit to PP/T/Vib/Prop/ LT,Coord: decreased speed and magnitude of FNF, Finger tapping and HKS, on left side only.,Station: mild LUE upward drift.,Gait: tendency to drift toward the left. Difficulty standing on LLE.,Reflexes were symmetric, plantar responses were flexor bilaterally.,Gen exam unremarkable.,COURSE: ,Admit Labs: ESR, PT/PTT, GS, UA, EKG, and HCT were unremarkable. Hgb 13.9, Hct 41%, Plt 280k, WBC 5.5.,The patient was diagnosed with a probable lacunar stroke and entered into the TOAST study (Trial of ORG10172[a low molecular weight heparin] in Acute Stroke Treatment).,Carotid Duplex: 16-49%RICA and 0-15%LICA stenosis with anterograde vertebral artery flow, bilaterally. Transthoracic echocardiogram showed mild mitral regurgitation, mild tricuspid regurgitation and a left to right shunt. There was no evidence of blood clot.,Hospital course: 5 days after admission the patient began to complain of proximal LLE and left flank pain. On exam, she had weakness of the quadriceps and hip flexors of the LLE. Her pain increased with left hip flexion. In addition, she complained of paresthesias about the lateral aspect of the medial anterior left thigh; and upon on sensory testing, she had decreased PP/TEMP sensation in a left femoral nerve distribution. She denied any back/neck pain and the rest of her neurologic exam remained unchanged from admission.,Abdominal CT Scan, 2/4/96, revealed a large left retroperitoneal iliopsoas hematoma.,Hgb 8.9g/dl. She was transfused with 4 units of pRBCs. She underwent surgical decompression and evacuation of the hematoma via a posterior flank approach on 2/6/96. Her postoperative course was uncomplicated. She was discharged home on ASA.,At follow-up, on 2/23/96, she complained of left sided paresthesias (worse in the LLE than in the LUE) and feeling of "swollen left foot." These symptoms had developed approximately 1 month after her stroke. Her foot looked normal and her UE strength was 5/4+ proximally and distally, and LE strength 5/4+ proximally and 5/5- distally. She was ambulatory. There was no evidence of LUE upward drift. A somatosensory evoked potential study revealed an absent N20 and normal P14 potentials. This was suggestive of a lesion involving the right thalamus which might explain her paresthesia/dysesthesia as part of a Dejerine-Roussy syndrome.
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DESCRIPTION: Left Iliopsoas hematoma.  Gait difficulty.

The presented medical scenario involves a 59-year-old female patient with a history of sudden gait difficulty and weakness, diagnosed with a probable lacunar stroke subsequently developing into an iliopsoas hematoma that required surgical intervention. The complexity and urgency of managing a suspected stroke, surgical intervention for a hematoma, and the subsequent post-operative neurologic follow-ups suggest significant medical stakes. The condition affects major functions like mobility and sensation, making accurate diagnosis and treatment critical.


Medical Specialty: Neurology
Sample Name: CT Lumbar Spine

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

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

The CT scan was performed on an emergency basis to investigate the cause of a patient's left lower extremity muscle spasm, which could be related to various degenerative changes and potential nerve root involvement in the lumbar spine. However, the findings are indicative of advanced degenerative disk disease and some stenosis, which are chronic conditions that typically require management rather than immediate critical intervention. There is no indication of acute injury such as fractures or severe nerve compression that would necessitate emergency surgical intervention. Therefore, the situation involves managing symptoms of chronic conditions, not life-threatening matters.


Medical Specialty: Consult - History and Phy.
Sample Name: Consult - Atrial Fibrillation

REASON FOR CONSULTATION:,  Atrial fibrillation.,HISTORY OF PRESENT ILLNESS:,  The patient is a 78-year-old, Hispanic woman with past medical history significant for coronary artery disease status post bypass grafting surgery and history of a stroke with residual left sided hemiplegia.  Apparently, the patient is a resident of Lake Harris Port Square long-term facility after her stroke.  She was found to have confusion while in her facility.  She then came to the emergency room and found to have a right sided acute stroke.  12-lead EKG performed on August 10, 2009, found to have atrial fibrillation.  Telemetry also revealed atrial fibrillation with rapid ventricular response.  Currently, the telemetry is normal sinus rhythm.  Because of the finding of atrial fibrillation, cardiology was consulted.,The patient is a poor historian.  She did not recall why she is in the hospital, she said she had a stroke.  She reported no chest discomfort, no shortness of breath, no palpitations.,The following information was obtained from the patient's chart:,PAST MEDICAL HISTORY:,1.  Coronary artery disease status post bypass grafting surgery.  Unable to obtain the place, location, anatomy, and the year it was performed.,2.  Carotid artery stenosis status post right carotid artery stenting.  Again, the time was unknown.,3.  Diabetes.,4.  Hypertension.,5.  Hyperlipidemia.,6.  History of stroke with left side hemiplegia.,ALLERGIES: , No known drug allergies.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY:,  The patient is a resident of Lake Harris Port Square.  She has no history of alcohol use.,CURRENT MEDICATIONS: , Please see attached list including hydralazine, Celebrex, Colace, metformin, aspirin, potassium, Lasix, Levaquin, Norvasc, insulin, Plavix, lisinopril, and Zocor.,REVIEW OF SYSTEMS: , Unable to obtain.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Blood pressure 133/44, pulse 98, O2 saturation is 98% on room air.  Temperature 99, respiratory rate 16.,GENERAL:  The patient is sitting in the chair at bedside.  Appears comfortable.  Left facial droop.  Left side hemiplegia.,HEAD AND NECK:  No JVP seen.  Right side carotid bruit heard.,CHEST:  Clear to auscultation bilaterally.,CARDIOVASCULAR:  PMI not displaced, regular rhythm.  Normal S1 and S2.  Positive S4.  There is a 2/6 systolic murmur best heard at the left lower sternal border.,ABDOMEN:  Soft.,EXTREMITIES:  Not edematous.,DATA:,  A 12-lead EKG performed on August 9, 2009, revealed atrial fibrillation with a ventricular rate of 96 beats per minute, nonspecific ST wave abnormality.,Review of telemetry done the last few days, currently the patient is in normal sinus rhythm at the rate of 60 beats per minute.  Atrial fibrillation was noted on admission noted August 8 and August 10; however, there was normal sinus rhythm on August 10.,LABORATORY DATA: , WBC 7.2, hemoglobin 11.7.  The patient's hemoglobin was 8.2 a few days ago before blood transfusion.  Chemistry-7 within normal limits.  Lipid profile:  Triglycerides 64, total cholesterol 106, HDL 26, LDL 17.  Liver function tests are within normal limits.  INR was 1.1.,A 2D echo was performed on August 11, 2009, and revealed left ventricle normal in size with EF of 50%.  Mild apical hypokinesis.  Mild dilated left atrium.  Mild aortic regurgitation, mitral regurgitation, and tricuspid regurgitation.  No intracardiac masses or thrombus were noted.  The aortic root was normal in size.,ASSESSMENT AND RECOMMENDATIONS:,1.  Paroxysmal atrial fibrillation.  It is unknown if this is a new onset versus a paroxysmal atrial fibrillation.  Given the patient has a recurrent stroke, anticoagulation with Coumadin to prevent further stroke is indicated.  However, given the patient's current neurologic status, the safety of falling is unclear.  We need to further discuss with the patient's primary care physician, probably rehab physician.  If the patient's risk of falling is low, then Coumadin is indicated.  However, if the patient's risk for falling is high, then a course using aspirin and Plavix will be recommended.  Transesophageal echocardiogram probably will delineate possible intracardiac thrombus better, however will not change our current management.  Therefore, I will not recommend transesophageal echocardiogram at this point.  Currently, the patient's heart rate is well controlled, antiarrhythmic agent is not recommended at this point.,2.  Carotid artery stenosis.  The patient underwent a carotid Doppler ultrasound on this admission and found to have a high-grade increased velocity of the right internal carotid artery.  It is difficult to assess the severity of the stenosis given the history of possible right carotid stenting.  If clinically indicated, CT angio of the carotid will be indicated to assess for stent patency.  However, given the patient's current acute stroke, revascularization is not indicated at this time.,3.  Coronary artery disease.  Clinically stable.  No further test is indicated at this time.
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DESCRIPTION: Patient with past medical history significant for coronary artery disease status post bypass grafting surgery and history of a stroke with residual left sided hemiplegia.

The consultation involves a 78-year-old patient with a complex medical history, including coronary artery disease, stroke, diabetes, and newly found atrial fibrillation. The situation is high-stakes due to the risk factors associated with both recurrent strokes and atrial fibrillation, such as the need for careful management of anticoagulation therapy to prevent further strokes while balancing the risk of falls. The medical decisions made could have significant consequences on the patient's health outcomes, making it crucial for appropriate, timely medical management.


Medical Specialty: Urology
Sample Name: Urinary Frequency & Urgency - Followup

HISTORY OF PRESENT ILLNESS:  ,This is a 55-year-old female with a history of stroke, who presents today for followup of frequency and urgency with urge incontinence.  This has been progressively worsening, and previously on VESIcare with no improvement.  She continues to take Enablex 50 mg and has not noted any improvement of her symptoms.  The nursing home did not do a voiding diary.  She is accompanied by her power of attorney.  No dysuria, gross hematuria, fever or chills.  No bowel issues and does use several Depends a day.,Recent urodynamics in April 2008, here in the office, revealed significant detrusor instability with involuntary urinary incontinence and low bladder volumes, and cystoscopy was unremarkable.,IMPRESSION:  ,Persistent frequency and urgency, in a patient with a history of neurogenic bladder and history of stroke.  This has not improved on VESIcare as well as Enablex.  Options are discussed.,We discussed other options of pelvic floor rehabilitation, InterStim by Dr. X, as well as more invasive procedure.  The patient and the power of attorney would like him to proceed with meeting Dr. X to discuss InterStim, which was briefly reviewed here today and brochure for this is provided today.  Prior to discussion, the nursing home will do an extensive voiding diary for one week, while she is on Enablex, and if this reveals no improvement, the patient will be started on Ventura twice daily and prescription is provided.  They will see Dr. X with a prior voiding diary, which is again discussed.  All questions answered.,PLAN:,  As above, the patient will be scheduled to meet with Dr. X to discuss option of InterStim, and will be accompanied by her power of attorney.  In the meantime, Sanctura prescription is provided, and voiding diaries are provided.  All questions answered.
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DESCRIPTION: Persistent frequency and urgency, in a patient with a history of neurogenic bladder and history of stroke.

urology, neurogenic bladder, urge incontinence, urgency, frequency, vesicare, enablex, persistent frequency and urgency, frequency and urgency, persistent frequency, voiding diary, voiding

This medical situation involves persistent urinary issues in a patient with a history of neurogenic bladder and stroke. The patient has not responded to previous treatments, and is considering a more invasive procedure (InterStim). The decision involves consulting with a specialist and requires careful consideration, especially with the involvement of the patient's power of attorney. Despite being a significant health issue, the situation doesn't point to an immediate life-threatening condition. However, it requires timely attention to improve the patient's quality of life.


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

Medical Specialty: Obstetrics / Gynecology
Sample Name: Ultrasound - Transvaginal

EXAM: , Transvaginal ultrasound.,HISTORY: , Pelvic pain.,FINDINGS: , The right ovary measures 1.6 x 3.4 x 2.0 cm.  There are several simple-appearing probable follicular cysts. There is no abnormal flow to suggest torsion on the right.  Left ovary is enlarged, demonstrating a 6.0 x 3.5 x 3.7 cm complex cystic mass of uncertain etiology.  This could represent a large hemorrhagic cyst versus abscess.  There is no evidence for left ovarian torsion.  There is a small amount of fluid in the cul-de-sac likely physiologic.,The uterus measures 7.7 x 5.0 cm.  The endometrial echo is normal at 6 mm.,IMPRESSION:,1.  No evidence for torsion.,2.  Large, complex cystic left ovarian mass as described.  This could represent a large hemorrhagic cyst; however, an abscess/neoplasm cannot be excluded.  Recommend either short interval followup versus laparoscopic evaluation given the large size and complex nature.
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DESCRIPTION: Transvaginal ultrasound to evaluate pelvic pain.

obstetrics / gynecology, ultrasound, pelvic pain, transvaginal, cul-de-sac, cystic mass, echo, endometrial, flow, follicular cysts, hemorrhagic cyst, laparoscopic, neoplasm, ovarian, ovary, uterus, transvaginal ultrasound, complex cystic, torsion,

The findings highlight a complex cystic mass on the left ovary, which could indicate a hemorrhagic cyst but also raises the possibility of an abscess or neoplasm. Although there is no immediate evidence of torsion, the size and nature of the mass necessitate further evaluation or surgical intervention. These considerations suggest a moderately high-stakes situation as it has significant implications for the patient's health and potential treatment paths, such as surgery to rule out malignancy.


Medical Specialty: Orthopedic
Sample Name: Cemented Arthroplasty

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

The situation involves a detailed surgical procedure for knee arthroplasty on an 84-year-old patient with significant osteoarthritis, which inherently carries risks and complexities typical of major surgeries in elderly patients. This includes concerns about anesthesia, potential for infection, and recovery challenges. However, this type of surgery is relatively common and routine for orthopedic surgeons, with a good standard of care and procedures to manage risks effectively. Therefore, the situation is high-stakes concerning patient health and surgical outcomes but manageable within the field's expertise.


Medical Specialty: Orthopedic
Sample Name: Wrist Pain

CHIEF COMPLAINT:,  Left wrist pain.,HISTORY OF PRESENT PROBLEM:,
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DESCRIPTION: Consultation for wrist pain.

Consultation for wrist pain.

orthopedic, wrist pain, scapholunate, tenderness to palpation, three views, traumatic wrist injury, ulnar styloid nonunion, ulnar styloid, wrist, union, soreness, styloid, ulnar,

The situation described involves a consultation for wrist pain, which is a common orthopedic issue. While it can be uncomfortable and impact daily activities, wrist pain generally does not pose an immediate threat to life or result in severe consequences. However, it can be indicative of an underlying condition that may need attention. Thus, the stakes are moderate considering the need for a proper diagnosis and treatment to prevent further complications.


Medical Specialty: Consult - History and Phy.
Sample Name: Consult - Multiple Colon Polyps

HISTORY OF PRESENT ILLNESS: , See chart attached.,MEDICATIONS: , Tramadol 50 mg every 4 to 6 hours p.r.n., hydrocodone 7.5 mg/500 mg every 6 hours p.r.n., zolpidem 10 mg at bedtime, triamterene 37.5 mg, atenolol 50 mg, vitamin D, TriCor 145 mg, simvastatin 20 mg, ibuprofen 600 mg t.i.d., and Lyrica 75 mg.,FAMILY HISTORY: , Mother is age 78 with history of mesothelioma.  Father is alive, but unknown medical history as they have been estranged.  She has a 51-year-old sister with history of multiple colon polyps.  She has 2 brothers, 1 of whom has schizophrenia, but she knows very little about their medical history.  To the best of her knowledge, there are no family members with stomach cancer or colon cancer.,SOCIAL HISTORY: , She was born in Houston, Texas and moved to Florida about 3 years ago.  She is divorced.  She has worked as a travel agent.  She has 2 sons ages 24 and 26, both of whom are alive and well.  She smokes a half a pack of cigarettes per day for more than 35 years.  She does not consume alcohol.,REVIEW OF SYSTEMS: , As per the form filled out in our office today is positive for hypertension, weakness in arms and legs, arthritis, pneumonia, ankle swelling, getting full quickly after eating, loss of appetite, weight loss, which is stated as fluctuating up and down 4 pounds, trouble swallowing, heartburn, indigestion, belching, nausea, diarrhea, constipation, change in bowel habits, change in consistency, rectal bleeding, hemorrhoids, abdominal discomfort and cramping associated with constipation, hepatitis A or infectious hepatitis in the past, and smoking and alcohol as previously stated.  Otherwise, review of systems is negative for strokes, paralysis, gout, cataracts, glaucoma, respiratory difficulties, tuberculosis, chest pain, heart disease, kidney stones, hematuria, rheumatic fever, scarlet fever, cancer, diabetes, thyroid disease, seizure disorder, blood transfusions, anemia, jaundice, or pruritus.,PHYSICAL EXAMINATION:  ,Weight 152 pounds.  Height is 5 feet 3 inches.  Blood pressure 136/80.  Pulse 68.  In general:  She is a well-developed and well-nourished female who ambulates with the assistance of a cane.  Neurologically nonfocal.  Awake, alert, and oriented x 3.  HEENT:  Head normocephalic, atraumatic.  Sclerae anicteric.  Conjunctivae are pink.  Mouth is moist without any obvious oral lesions.  Neck is supple.  There is no submandibular, submaxillary, axillary, supraclavicular, or epitrochlear adenopathy appreciable.  Lungs are clear to auscultation bilaterally.  Heart:  Regular rate and rhythm without obvious gallops or murmurs.  Abdomen is soft, nontender with good bowel sounds.  No organomegaly or masses are appreciable.  Extremities are without clubbing, cyanosis, and/or edema.  Skin is warm and dry.  Rectal was deferred and will be done at the time of the colonoscopy.,IMPRESSION:,1.  A 50-year-old female whose 51-year-old sister has a history of multiple colon polyps, which may slightly increase her risk for colon cancer in the future.,2.  Reports of recurrent bright red blood per rectum, mostly on the toilet paper over the past year.  Bleeding most likely consistent with internal hemorrhoids; however, she needs further evaluation for colon polyps or colon cancer.,3.  Alternations between constipation and diarrhea for the past several years with some lower abdominal cramping and discomfort particularly associated with constipation.  She is on multiple medications including narcotics and may have developed narcotic bowel syndrome.,4.  A long history of pyrosis, dyspepsia, nausea, and belching for many years relieved by antacids.  She may likely have underlying gastroesophageal reflux disease.,5.  A 1-year history of some early satiety and fluctuations in her weight up and down 4 pounds.  She may also have some GI dysmotility including gastroparesis.,6.  Report of dysphagia to solids over the past several years with a history of a bone spur in her cervical spine.  If this bone spur is pressing anteriorly, it could certainly cause recurrent symptoms of dysphagia.  Differential also includes peptic stricture or Schatzki's ring, and even remotely, the possibility of an esophageal malignancy.,7.  A history of infectious hepatitis in the past with some recent mild elevations in AST and ALT levels without clear etiology.  She may have some reaction to her multiple medications including her statin drugs, which can cause mild elevations in transaminases.  She may have some underlying fatty liver disease and differential could include some form of viral hepatitis such as hepatitis B or even C.,PLAN:,1.  We have asked her to follow up with her primary care physician with regard to this recent elevation in her transaminases.  She will likely have the lab tests repeated in the future, and if they remain persistently elevated, we will be happy to see her in the future for further evaluation if her primary care physician would like.,2.  Discussed reflux precautions and gave literature for further review.,3.  Schedule an upper endoscopy with possible esophageal dilatation, as well as colonoscopy with possible infrared coagulation of suspected internal hemorrhoids.  Both procedures were explained in detail including risks and complications such as adverse reaction to medication, as well as respiratory embarrassment, infection, bleeding, perforation, and possibility of missing a small polyp or tumor.,4.  Alternatives including upper GI series, flexible sigmoidoscopy, barium enema, and CT colonography were discussed; however, the patient agrees to proceed with the plan as outlined above.,5.  Due to her sister's history of colon polyps, she will likely be advised to have a repeat colonoscopy in 5 years or perhaps sooner pending the results of her baseline examination.,
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DESCRIPTION: A 50-year-old female whose 51-year-old sister has a history of multiple colon polyps, which may slightly increase her risk for colon cancer in the future.

consult - history and phy., mesothelioma, risk for colon cancer, constipation, diarrhea, multiple colon polyps, colon cancer, colon polyps, colon, cancer, polyps,

The situation involves a detailed medical consultation regarding multiple potential gastrointestinal and systemic issues in a patient, including a family history of colon polyps, which may increase her risk for colon cancer. The stakes are moderate to high due to the multiple symptoms and conditions requiring further evaluation and possible interventions like endoscopy and colonoscopy. However, this is part of a routine medical consultation process, not an immediate life-threatening emergency, although it does involve potentially serious conditions that require timely attention.


Medical Specialty: Surgery
Sample Name: Lateral Epicondylitis Release

PREOPERATIVE DIAGNOSIS:  ,Lateral epicondylitis.
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DESCRIPTION: Lateral release with lengthening of the ECRB tendon.  Lateral epicondylitis.

surgery, lateral release, ecrb tendon, ecrl, lateral epicondylitis, tourniquet, aponeurosis, epicondyle, antebrachial, epicondylitis, dissection, extensor, ecrb

Lateral epicondylitis, also known as tennis elbow, is a common condition causing pain around the outside of the elbow. The surgery for this condition, such as a lateral release with lengthening of the ECRB tendon, is usually elective and considered routine in nature. While all surgical procedures carry some inherent risks, this surgery is generally not considered high-stakes when compared to more complex or urgent surgeries.


Medical Specialty: Surgery
Sample Name: Cataract Extraction & Vitrectomy

PREOPERATIVE DIAGNOSIS: , Cataract to right eye.,POSTOPERATIVE DIAGNOSIS: , Cataract to right eye.,PROCEDURE PERFORMED:  ,Cataract extraction with intraocular lens implant of the right eye, anterior vitrectomy of the right eye.,LENS IMPLANT USED:  ,See below.,COMPLICATIONS: , Posterior capsular hole, vitreous prolapse.,ANESTHESIA:  ,Topical.,PROCEDURE IN DETAIL:  ,The patient was identified in the preoperative holding area before being escorted back to the operating room suite.  Hemodynamic monitoring was begun.  Time-out was called and the patient eye operated upon and lens implant intended were verbally verified.  Three drops of tetracaine were applied to the operative eye.  The patient was then prepped and draped in usual sterile fashion for intraocular surgery.  A lid speculum was placed.  Two paracentesis sites were created approximately 120 degrees apart straddling the temple using a slit knife.  The anterior chamber was irrigated with a dilute 0.25% solution of non-preserved lidocaine and filled with Viscoat.  The clear corneal temporal incision was fashioned.  The anterior chamber was entered by introducing a keratome.  The continuous tear capsulorrhexis was performed using the bent needle cystotome and completed with Utrata forceps.  The cataractous lens was then hydrodissected and phacoemulsified using a modified phaco-chop technique.  Following removal of the last nuclear quadrant, there was noted to be a posterior capsular hole nasally.  This area was tamponaded with Healon.  The anterior chamber was swept with a cyclodialysis spatula and there was noted to be vitreous prolapse.  An anterior vitrectomy was then performed bimanually until the vitreous was cleared from the anterior chamber area.  The sulcus area of the lens was then inflated using Healon and a V9002 16.0 diopter intraocular lens was unfolded and centered in the sulcus area with haptic secured in the sulcus.  There was noted to be good support.  Miostat was injected into the anterior chamber and viscoelastic agent rinsed out of the eye with Miostat.  Gentle bimanual irrigation, aspiration was performed to remove remaining viscoelastic agents anteriorly.  The pupil was noted to constrict symmetrically.  Wounds were checked with Weck-cels and found to be free of vitreous.  BSS was used to re-inflate the anterior chamber to normal depth as confirmed by tactile pressure at about 12.  All corneal wounds were then hydrated, checked and found to be watertight and free of vitreous.  A single 10-0 nylon suture was placed temporarily as prophylaxis and the knot buried.  Lid speculum was removed.  TobraDex ointment, light patch and a Soft Shield were applied.  The patient was taken to the recovery room, awake and comfortable.  We will follow up in the morning for postoperative check.  He will not be given Diamox due to his sulfa allergy.  The intraoperative course was discussed with both he and his wife.
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DESCRIPTION: Cataract to right eye.  Cataract extraction with intraocular lens implant of the right eye, anterior vitrectomy of the right eye.

surgery, intraocular lens implant, lid speculum, cataract extraction, anterior vitrectomy, anterior chamber, eye, intraocular, extraction, hemodynamic, implant, vitrectomy, vitreous, cataract, lens,

The situation involves a surgical procedure, specifically cataract extraction with vitrectomy, which can have significant implications if complications occur, such as the posterior capsular hole and vitreous prolapse noted here. While cataract surgery is typically low-risk, the presence of complications increases the stakes. Surgical execution and postoperative care are critical for maintaining vision quality and preventing further issues. Hence, the situation is moderately high-stakes compared to routine surgery.