Medical Specialty: Consult - History and Phy.
Sample Name: Decreased Vision Consult

She has a past ocular history including cataract extraction with lens implants in both eyes in 2001 and 2003.  She also has a history of glaucoma diagnosed in 1990 and macular degeneration.  She has been followed in her home country and is here visiting family.  She had the above-mentioned observation and was brought in on an urgent basis today.,Her past medical history includes hypertension and hypercholesterolemia and hypothyroidism.,Her medications include V-optic 0.5% eye drops to both eyes twice a day and pilocarpine 2% OU three times a day.  She took both the drops this morning.  She also takes Eltroxin which is for hypothyroidism, Plendil for blood pressure, and pravastatin.,She is allergic to Cosopt.,She has a family history of blindness in her brother as well as glaucoma and hypertension.,Her visual acuity today at distance without correction are 20/25 in the right and count fingers at 3 feet in the left eye.  Manifest refraction showed no improvement in either eye.  The intraocular pressures by applanation were 7 on the right and 18 in the left eye.  Gonioscopy showed grade 4 open angles in both eyes.  Humphrey visual field testing done elsewhere showed diffuse reduction in sensitivity in both eyes.  The lids were normal OU.  She has mild dry eye OU.  The corneas are clear OU.  The anterior chamber is deep and quiet OU.  Irides appear normal.  The lenses show well centered posterior chamber intraocular lenses OU.,Dilated fundus exam shows clear vitreous OU.  The optic nerves are normal in size.  They both appear to have mild pallor.  The optic cups in both eyes are shallow.  The cup-to-disc ratio in the right eye is not overtly large, would estimated 0.5 to 0.6; however, she does have very thin rim tissue inferotemporally in the right eye.  In the left eye, the glaucoma appears to be more advanced to the larger cup-to-disc ratio and a thinner rim tissue.,The macula on the right shows drusen with focal areas of RPE atrophy.  I do not see any evidence of neovascularization such as subretinal fluid, lipid or hemorrhage.  She does have a punctate area of RPE atrophy which is just adjacent to the fovea of the right eye.  In the left eye, she has also several high-risk drusen, but no evidence of neovascularization.  The RPE in the left eye does appear to be more diffusely abnormal although these changes do appear somewhat mild.  I do not see any dense or focal areas of frank RPE atrophy or hypertrophy.,The peripheral retinas are attached in both eyes.,Ms. ABC has pseudophakia OU which is stable and she is doing well in this regard.  She has glaucoma which likely is worse in the left eye and also likely explains her poor vision in the left eye.  The intraocular pressure in the mid-to-high teens in the left eye is probably high for her.  She has allergic reaction to Cosopt.  I will recommend starting Xalatan OS nightly.  I think the intraocular pressure in the right eye is acceptable and is probably a stable pressure for her OD.  She will need followup in the next 1 or 2 months after returning home to Israel later this week after starting the new medication which is Xalatan.,Regarding the macular degeneration, she has had high-risk changes in both eyes.  The vision in the right eye is good, but she does have a very concerning area of RPE atrophy just adjacent to the fovea of the right eye.  I strongly recommend that she see a retina specialist before returning to Israel in order to fully discuss prophylactic measures to prevent worsening of her macular degeneration in the right eye.
---
DESCRIPTION: One-week history of decreased vision in the left eye.  Past ocular history includes cataract extraction with lens implants in both eyes.

consult - history and phy., cataract extraction, lens implants, decreased vision, macular degeneration, intraocular pressures, rpe atrophy, eye, degeneration, glaucoma, macular, vision,

The situation involves a patient with complex ocular history and current issues that could potentially lead to severe vision loss if not managed properly. Conditions like glaucoma and macular degeneration are serious and require careful, ongoing monitoring and treatment. Additionally, there is a history of family blindness, adding a layer of genetic risk. Given that the patient needs to see a specialist soon before returning home, there are immediate logistical implications for her treatment plan. Therefore, the stakes are high because inadequate attention could lead to permanent vision impairment.


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

Medical Specialty: General Medicine
Sample Name: Gen Med Consult - 20

SUBJECTIVE:,  This is an 11-year-old female who comes in for two different things.  1.  She was seen by the allergist.  No allergies present, so she stopped her Allegra, but she is still real congested and does a lot of snorting.  They do not notice a lot of snoring at night though, but she seems to be always like that.  2.  On her right great toe, she has got some redness and erythema.  Her skin is kind of peeling a little bit, but it has been like that for about a week and a half now.,PAST MEDICAL HISTORY:,  Otherwise reviewed and noted.,CURRENT MEDICATIONS:,  None.,ALLERGIES TO MEDICINES:,  None.,FAMILY SOCIAL HISTORY:,  Everyone else is healthy at home.,REVIEW OF SYSTEMS:,  She has been having the redness of her right great toe, but also just a chronic nasal congestion and fullness.  Review of systems is otherwise negative.,PHYSICAL EXAMINATION:,General:  Well-developed female, in no acute distress, afebrile.,HEENT:  Sclerae and conjunctivae clear.  Extraocular muscles intact.  TMs clear.  Nares patent.  A little bit of swelling of the turbinates on the left.  Oropharynx is essentially clear.  Mucous membranes are moist.,Neck:  No lymphadenopathy.,Chest:  Clear.,Abdomen:  Positive bowel sounds and soft.,Dermatologic:  She has got redness along the lateral portion of her right great toe, but no bleeding or oozing.  Some dryness of her skin.  Her toenails themselves are very short and even on her left foot and her left great toe the toenails are very short.,ASSESSMENT:,1.  History of congestion, possibly enlarged adenoids, or just her anatomy.,2.  Ingrown toenail, but slowly resolving on its own.,PLAN:,1.  For the congestion, we will have ENT evaluate.  Appointment has been made with Dr. XYZ for in a couple of days.,2.  I told her just Neosporin for her toe, letting the toenail grow out longer.  Call if there are problems.
---
DESCRIPTION: 11-year-old female.  History of congestion, possibly enlarged adenoids.

general medicine, enlarged adenoids, adenoids, oropharynx, congestion, toenails, toe,

The medical case involves an 11-year-old female with minor, non-life-threatening issues: chronic nasal congestion and a resolving ingrown toenail. These conditions, while potentially uncomfortable, are not urgent or critical. There is a plan in place, including an ENT evaluation and basic treatment for the toe, reflecting that medical action can proceed without immediate high risks or severe outcomes. The patient's general well-being is normal, with no acute distress noted.

Filled in based on scale_labels and scale_label_confidence


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

CC:, Fall with questionable associated loss of consciousness.,HX: ,This 81 y/o RHM fell down 20 steps on the evening of admission, 1/10/93, while attempting to put his boots on at the top of the staircase. He was evaluated locally and was amnestic to the event at the time of examination. A HCT scan was obtained and he was transferred to UIHC, Neurosurgery.,MEDS:, Lasix 40mg qd, Zantac 150mg qd, Lanoxin 0.125mg qd, Capoten 2.5mg bid, Salsalate 750mg tid, ASA 325mg qd, "Ginsana" (Ginseng) 100mg bid.,PMH: ,1)Atrial fibrillation, 2)Right hemisphere stroke, 11/22/88, with associated left hemiparesis and amaurosis fugax. This was followed by a RCEA, 12/1/88 for 98% stenosis. The stroke symptoms/signs resolved. 3)DJD, 4)Right TKR 2-3 years ago, 5)venous stasis; with no h/o DVT, 6)former participant in NASCET, 7)TURP for BPH. No known allergies.,FHX:, Father died of an MI at unknown age, Mother died of complications of a dental procedure. He has one daughter who is healthy.,SHX:, Married. Part-time farmer. Denied tobacco/ETOH/illicit drug use.,EXAM: ,BP157/86, HR100 and irregular, RR20, 36.7C, 100%SaO2,MS: A&O to person, place, time. Speech fluent and without dysarthria.,CN: Pupils 3/3 decreasing to 2/2 on exposure to light. EOM intact. VFFTC. Optic disks were flat. Face was symmetric with symmetric movement. The remainder of the CN exam was unremarkable.,Motor: 5/5 strength throughout with normal muscle tone and bulk.,Sensory: unremarkable.,Coord: unremarkable.,Station/Gait: not mentioned in chart.,Reflexes: symmetric. Plantar responses were flexor, bilaterally.,Gen Exam: CV:IRRR without murmur. Lungs: CTA. Abdomen: NT, ND, NBS.,HEENT: abrasion over the right forehead.,Extremity: distal right leg edema/erythema (just above the ankle). tender to touch.,COURSE:, 1/10/93, (outside)HCT was reviewed, It revealed a left parietal epidural hematoma. GS, PT/PTT, UA, and CBC were unremarkable. RLE XR revealed a fracture of the right lateral malleolus for which he was casted. Repeat HCTs showed no change in the epidural hematoma and he was discharged home on DPH.
---
DESCRIPTION: Fall with questionable associated loss of consciousness.  Left parietal epidural hematoma.

consult - history and phy., loss of consciousness, parietal epidural hematoma, parietal epidural, epidural hematoma, consciousness, epidural, hematoma,

The case involves an elderly patient who experienced a significant fall resulting in a left parietal epidural hematoma and a fracture. Epidural hematomas, particularly in elderly patients, can be serious due to the risk of increased intracranial pressure, potential for rapid neurological deterioration, and the patient's age and pre-existing conditions like atrial fibrillation and history of stroke. The situation requires careful monitoring and potentially urgent medical intervention to prevent serious outcomes, making it high-stakes.


Medical Specialty: Podiatry
Sample Name: Gangrene Surgery

PREOPERATIVE DIAGNOSIS: , Gangrene osteomyelitis, right second toe.,POSTOPERATIVE DIAGNOSIS: , Gangrene osteomyelitis, right second toe.,OPERATIVE REPORT:  ,The patient is a 58-year-old female with poorly controlled diabetes with severe lower extremity lymphedema.  The patient has history of previous right foot infection requiring first ray resection.  The patient has ulcerations of right second toe dorsally at the proximal interphalangeal joint, which has failed to respond to conservative treatment.  The patient now has exposed bone and osteomyelitis in the second toe.  The patient has been on IV antibiotics as an outpatient and has failed to respond to these and presents today for surgical intervention.,After an IV was started by the Department of Anesthesia, the patient was taken back to the operating room and placed on the operative table in the supine position.  A restraint belt was placed around the patient's waist using copious amounts of Webril and an ankle pneumatic tourniquet was placed around the patient's right ankle and the patient was made comfortable by the Department of Anesthesia.  After adequate amounts of sedation had been given to the patient, we administered a block of 10 cc of 0.5% Marcaine plain in proximal digital block around the second digit.  The foot and ankle were then prepped in the normal sterile orthopedic manner.  The foot was elevated and an Esmarch bandage applied to exsanguinate the foot.  The tourniquet was then inflated to 250 mmHg and the foot was brought back onto the table.  Using Band-Aid scissors, the stockinet was cut and reflected and using a wet and dry sponge, the foot was wiped, cleaned, and the second toe identified.,Using a skin scrape, a racket type incision was planned around the second toe to allow also remodelling of previous operative site.  Using a fresh #10 blade, skin incision was made circumferentially in the racket-shaped manner around the second digit.  Then, using a fresh #15 blade, the incision was deepened and was taken down to the level of the second metatarsophalangeal joint.  Care was taken to identify bleeders and cautery was used as necessary for hemostasis.  After cleaning up all the soft tissue attachments, the second digit was disarticulated down to the level of the metatarsophalangeal joint.  The head of the second metatarsal was inspected and was noted to have good glistening white cartilage with no areas of erosion evident by visual examination.  Attention was then directed to closure of the wound.  All remaining tissue was noted to be healthy and granular in appearance with no necrotic tissue evident.  Areas of subcutaneous tissue were then removed through a sharp dissection in order to allow better approximation of the skin edges.  Due to long-standing lower extremity lymphedema and postoperative changes on previous surgery, I thought that we were unable to close the incision in entirety.  Therefore, after copious amounts of irrigation using sterile saline, it was determined to use modified dental rolls using #4-0 gauze to remove tension from the skin.  Deep vertical mattress sutures were used in order to reapproximate more closely, the skin edges and bring the plantar flap of skin up to the dorsal skin.  This was obtained using #2-0 nylon suture.  Following this, the remaining exposed tissue from the wound was covered using moist to dry saline soaked 4 x 4 gauze.  The wound was then dressed using 4 x 4 gauze fluffed with abdominal pads, then using Kling and Kerlix and an ACE bandage to provide compression.  The tourniquet was deflated at 42 minutes' time and hemostasis was noted to be achieved.  The ACE bandage was extended up to just below the knee and no bleeding striking to the bandages was appreciated.  The patient tolerated the procedure well and was escorted to the Postanesthesia Care Unit with vital signs stable and vascular status intact, as was evidenced by capillary bleeding, which was present during the procedure.  Sedation was given postoperative introductions, which include to remain nonweightbearing to her right foot.  The patient was instructed to keep the foot elevated and to apply ice behind her knee as necessary, no more than 20 minutes each hour.  The patient was instructed to continue her regular medications.  The patient was to continue IV antibiotic course and was given prescription for Vicoprofen to be taken q.4h. p.r.n. for moderate to severe pain #30.  The patient will followup with Podiatry on Monday morning at 8:30 in the Podiatry Clinic for dressing change and evaluation of her foot at that time.,The patient was instructed as to signs and symptoms of infection, was instructed to return to the Emergency Department immediately if these should present.  The second digit was sent to Pathology for gross and micro.
---
DESCRIPTION: Gangrene osteomyelitis, right second toe.  The patient is a 58-year-old female with poorly controlled diabetes with severe lower extremity lymphedema.  The patient has history of previous right foot infection requiring first ray resection.

podiatry, dorsally, toe, ulcerations, foot infection, ray resection, metatarsophalangeal joint, ace bandage, gangrene osteomyelitis, foot, infection, gangrene, digital,

The situation involves a surgical procedure on a patient with gangrene osteomyelitis in the right second toe, compounded by poorly controlled diabetes and severe lymphedema. This is a high-stakes medical scenario because of the serious nature of the conditions involved, the patient's existing health complications, the risk of further infections, and the potential for amputation or worse outcomes if not managed properly. However, it is a routine procedure known to the medical professionals involved, and proper postoperative care and instructions reduce some of the risks. Therefore, while serious, it is not at the highest level of high-stakes situations like a life-threatening emergency surgery.


Medical Specialty: Consult - History and Phy.
Sample Name: OB/GYN Consultation - 3

Pap smear in November 2006 showed atypical squamous cells of undetermined significance.  She has a history of an abnormal Pap smear.  At that time, she was diagnosed with CIN 3 as well as vulvar intraepithelial neoplasia.  She underwent a cone biopsy that per her report was negative for any pathology.  She had no vulvar treatment at that time.  Since that time, she has had normal Pap smears.  She denies abnormal vaginal bleeding, discharge, or pain.  She uses Yaz for birth control.  She reports one sexual partner since 1994 and she is a nonsmoker.,She states that she has a tendency to have yeast infections and bacterial vaginosis.  She is also being evaluated for a possible interstitial cystitis because she gets frequent urinary tract infections.  She had a normal mammogram done in August 2006 and a history of perirectal condyloma that have been treated by Dr. B.  She also has a history of chlamydia when she was in college.,PAST MEDICAL HX: , Depression.,PAST SURGICAL HX: , None.,MEDICATIONS: , Lexapro 10 mg a day and Yaz.,ALLERGIES: , NO KNOWN DRUG ALLERGIES.,OB HX: , Normal spontaneous vaginal delivery at term in 2001 and 2004, Abc weighed 8 pounds 7 ounces and Xyz weighed 10 pounds 5 ounces.,FAMILY HX:  ,Maternal grandfather who had a MI which she reports is secondary to tobacco and alcohol use.  He currently has metastatic melanoma, mother with hypertension and depression, father with alcoholism.,SOCIAL HX:,  She is a public relations consultant.  She is a nonsmoker, drinks infrequent alcohol and does not use drugs.  She enjoys horseback riding and teaches jumping.,PE: , VITALS: Height: 5 feet 6 inches.  Weight: 139 lb.  BMI: 22.4.  Blood Pressure: 102/58.  GENERAL: She is well-developed and well-nourished with normal habitus and no deformities.  She is alert and oriented to time, place, and person and her mood and affect is normal.  NECK: Without thyromegaly or lymphadenopathy.  LUNGS: Clear to auscultation bilaterally.  HEART: Regular rate and rhythm without murmurs.  BREASTS: Deferred.  ABDOMEN: Soft, nontender, and nondistended.  There is no organomegaly or lymphadenopathy.  PELVIC: Normal external female genitalia.  Vulva, vagina, and urethra, within normal limits.  Cervix is status post cone biopsy; however, the transformation zone grossly appears normal and cervical discharge is clear and normal in appearance.  GC and chlamydia cultures as well as a repeat Pap smear were done.,Colposcopy is then performed without and with acetic acid.  This shows an entirely normal transformation zone, so no biopsies are taken.  An endocervical curettage is then performed with Cytobrush and curette and sent to pathology.  Colposcopy of the vulva is then performed again with acetic acid.  There is a thin strip of acetowhite epithelium located transversely on the clitoral hood that is less than a centimeter in diameter.  There are absolutely no abnormal vessels within this area.  The vulvar colposcopy is completely within normal limits.,A/P: , ASCUS Pap smear with history of a cone biopsy in 1993 and normal followup.,We will check the results of the Pap smear, in addition we have ordered DNA testing for high-risk HPV.  We will check the results of the ECC.  She will return in two weeks for test results.  If these are normal, she will need two normal Pap smears six months apart, and I think followup colposcopy for the vulvar changes.
---
DESCRIPTION: Consultation for an ASCUS Pap smear.

Consultation for an ASCUS Pap smear.

consult - history and phy., lmp, ascus, pap smear, abnormal pap smear, atypical, bacterial vaginosis, chlamydia, cone biopsy, infection, interstitial cystitis, intraepithelial, mammogram, neoplasia, perirectal condyloma, squamous, vaginal bleeding, vulvar, yeast infection, pap smears, pap, ob/gyn, colposcopy, smear,

The situation involves a consultation for a patient with a history of gynecological issues, notably an ASCUS Pap smear, a history of CIN 3, and previous treatments. While the medical history includes potentially serious conditions like intraepithelial neoplasia, the current situation described involves routine follow-up procedures like Pap smears and colposcopies which are standard in monitoring cervical health. The patient doesn't exhibit any alarming symptoms currently and the initial tests in this consultation show normal results, indicating no immediate high-risk factors present. Therefore, while monitoring is important, the stakes are more moderate than high.


Medical Specialty: Radiology
Sample Name: Transesophageal Echocardiogram - 3

REASON FOR EXAM: , Aortic valve replacement.  Assessment of stenotic valve.  Evaluation for thrombus on the valve.,PREOPERATIVE DIAGNOSIS:  ,Atrial valve replacement.,POSTOPERATIVE DIAGNOSES:,  Moderate stenosis of aortic valve replacement.  Mild mitral regurgitation.  Normal left ventricular function.,PROCEDURES IN DETAIL: , The procedure was explained to the patient with risks and benefits.  The patient agreed and signed the consent form.  The patient received a total of 3 mg of Versed and 50 mcg of fentanyl for conscious sedation and pain control.  The oropharynx anesthetized with benzocaine spray and lidocaine solution.,Esophageal intubation was done with no difficulty with the second attempt.  In a semi-Fowler position, the probe was passed to transthoracic views at about 40 to 42 cm.  Multiple pictures obtained.  Assessment of the peak velocity was done later.,The probe was pulled to the mid esophageal level.  Different pictures including short-axis views of the aortic valve was done.  Extubation done with no problems and no blood on the probe.  The patient tolerated the procedure well with no immediate postprocedure complications.,INTERPRETATION: , The left atrium was mildly dilated.  No masses or thrombi were seen.  The left atrial appendage was free of thrombus.  Pulse wave interrogation showed peak velocities of 60 cm per second.,The left ventricle was normal in size and contractility with mild LVH.  EF is normal and preserved.,The right atrium and right ventricle were both normal in size.,Mitral valve showed no vegetations or prolapse.  There was mild-to-moderate regurgitation on color flow interrogation.  Aortic valve was well-seated mechanical valve, bileaflet with acoustic shadowing beyond the valve noticed.  No perivalvular leak was noticed.  There was increased velocity across the valve with peak velocity of 3.2 m/sec with calculated aortic valve area by continuity equation at 1.2 cm2 indicative of moderate aortic valve stenosis based on criteria for native heart valves.,No AIC.,Pulmonic valve was somewhat difficult to see because of acoustic shadowing from the aortic valve.  Overall showed no abnormalities.  The tricuspid valve was structurally normal.,Interatrial septum appeared to be intact, confirmed by color flow interrogation as well as agitated saline contrast study.,The aorta and aortic arch were unremarkable.  No dissection.,IMPRESSION:,1.  Mildly dilated left atrium.,2.  Mild-to-moderate regurgitation.,3.  Well-seated mechanical aortic valve with peak velocity of 3.2 m/sec and calculated valve area of 1.2 cm2 consistent with moderate aortic stenosis.  Reevaluation in two to three years with transthoracic echocardiogram will be recommended.
---
DESCRIPTION: Transesophageal echocardiographic examination report.   Aortic valve replacement.  Assessment of stenotic valve.  Evaluation for thrombus on the valve.

radiology, aortic valve replacement, stenotic valve, thrombus, stenosis, ventricular, esophageal, peak velocity, valve replacement, aortic valve, aortic, transesophageal, valve, oropharynx, atrium, interrogation, atrial, moderate,

The provided scenario involves a medical diagnostic procedure, specifically a transesophageal echocardiogram, typically used to assess the condition of heart valves and related structures, especially after aortic valve replacement. The findings indicate moderate aortic stenosis and mild mitral regurgitation, necessitating monitoring and a follow-up in a few years. While such a diagnosis is important and warrants attention, it is not immediately life-threatening as long as it is managed correctly and monitored over time. Thus, it is moderately important but not critical in the short term.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: MRI of Lung - Adenocarcinoma

CC:, Found unresponsive.,HX: ,  39 y/o RHF complained of a severe HA at 2AM 11/4/92. It was unclear whether she had been having HA prior to this. She took an unknown analgesic, then vomited, then lay down in bed with her husband. When her husband awoke at 8AM he found her unresponsive with "stiff straight arms" and a "strange breathing pattern." A Brain CT scan revealed a large intracranial mass. She was intubated and hyperventilated to ABG (7.43/36/398). Other local lab values included: WBC 9.8, RBC 3.74, Hgb 13.8, Hct 40.7, Cr 0.5, BUN 8.5, Glucose 187, Na 140, K 4.0, Cl 107. She was given Mannitol 1gm/kg IV load, DPH 20mg/kg IV load, and transferred by helicopter to UIHC.,PMH:, 1)Myasthenia Gravis for 15 years, s/p Thymectomy,MEDS:, Imuran, Prednisone, Mestinon, Mannitol, DPH, IV NS,FHX/SHX:, Married. Tobacco 10 pack-year; quit nearly 10 years ago. ETOH/Substance Abuse unknown.,EXAM:, 35.8F, 99BPM, BP117/72, Mechanically ventilated at a rate of 22RPM on !00%FiO2. Unresponsive to verbal stimulation. CN: Pupils 7mm/5mm and unresponsive to light (fixed). No spontaneous eye movement or blink to threat. No papilledema or intraocular hemorrhage noted. Trace corneal reflexes bilaterally. No gag reflex. No oculocephalic reflex. MOTOR/SENSORY: No spontaneous movement. On noxious stimulation (Deep nail bed pressure) she either extended both upper extremities (RUE>LUE), or withdrew the stimulated extremity (right > left). Gait/Station/Coordination no tested. Reflexes: 1+ on right and 2+ on left with bilateral Babinski signs.,HCT 11/4/92: Large heterogeneous mass in the right temporal-parietal region causing significant parenchymal distortion and leftward subfalcine effect . There is low parenchymal density within the white matter. A hyperdense ring lies peripherally and may represent hemorrhage or calcification. The mass demonstrates inhomogeneous enhancement with contrast.,COURSE:, Head of bed elevated to 30 degrees, Mannitol and DPH were continued. MRI of Brain demonstrated a large right parietal mass with necrotic appearing center and leftward shift of midline structures. She underwent surgical resection of the tumor. Pathological analysis was consistent with adenocarcinoma. GYN exam, CT Abdomen and Pelvis, Bone scan were unremarkable. CXR revealed an right upper lobe lung nodule. She did not undergo thoracic biopsy due to poor condition. She received 3000 cGy cranial XRT in ten fractions and following this was discharged to a rehabilitation center.,In March, 1993 the patient exhibited right ptosis, poor adduction and abduction OD, 4/4 strength in the upper extremities and 5-/5- strength in the lower extremities. She was ambulatory with an ataxic gait.,She was admitted on 7/12/93 for lower cervical and upper thoracic pain, paraparesis and T8 sensory level. MRI brainstem/spine on that day revealed decreased T1 signal in the C2, C3, C6 vertebral bodies, increased T2 signal in the anterior medulla, and tectum, and spinal cord (C7-T3). Following injection of Gadolinium there was diffuse leptomeningeal enhancement from C7-T7 These findings were felt consistent with metastatic disease including possible leptomeningeal spread. Neurosurgery and Radiation Oncology agreed that the patients symptoms could be due to either radiation injury and/or metastasis. The patient was treated with Decadron and analgesics and discharged to a hospice center (her choice). She died a few months later.
---
DESCRIPTION: MRI: Right parietal metastatic adenocarcinoma (LUNG) metastasis.

cardiovascular / pulmonary, mri, lung, metastatic adenocarcinoma, parietal, breathing pattern, cranial xrt, t1 signal, sensory level, iv load, adenocarcinoma, metastatic, leptomeningeal

The case involves a patient with a history of myasthenia gravis who was found unresponsive due to a brain mass identified as metastatic adenocarcinoma originating from the lung. This situation includes complex medical conditions and a series of interventions, indicating a high-stakes scenario. The course of treatment involves critical decision-making, some of which include surgical resection, radiation therapy, and ultimately, hospice care. Such a scenario would typically involve significant implications for patient outcomes, requiring coordination across multiple specialties and addressing both the immediate and long-term prognosis of metastatic cancer.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Broviac Catheter Placement

PREOPERATIVE DIAGNOSES:,1.  Lumbar osteomyelitis.,2.  Need for durable central intravenous access.,POSTOPERATIVE DIAGNOSES:,1.  Lumbar osteomyelitis.,2.  Need for durable central intravenous access.,ANESTHESIA:,  General.,PROCEDURE:,  Placement of left subclavian 4-French Broviac catheter.,INDICATIONS:  ,The patient is a toddler admitted with a limp and back pain, who was eventually found on bone scan and septic workup to have probable osteomyelitis of the lumbar spine at disk areas.  The patient needs prolonged IV antibiotic therapy, but attempt at a PICC line failed.  She has exhausted most of her easy peripheral IV access routes and referral was made to the Pediatric Surgery Service for Broviac placement.  I met with the patient's mom.  With the help of a Spanish interpreter, I explained the technique for Broviac placement.  We discussed the surgical risks and alternatives, most of which have been exhausted.  All their questions have been answered, and the patient is fit for operation today.,DESCRIPTION OF OPERATION:  ,The patient came to the operating room and had an uneventful induction of general anesthesia.  We conducted a surgical time-out to reiterate all of the patient's important identifying information and to confirm that we were here to place the Broviac catheter.  Preparation and draping of her skin was performed with chlorhexidine based prep solution and then an infraclavicular approach to left subclavian vein was performed.  A flexible guidewire was inserted into the central location and then a 4-French Broviac catheter was tunneled through the subcutaneous tissues and exiting on the right anterolateral chest wall well below and lateral to the breast and pectoralis major margins.  The catheter was brought to the subclavian insertion site and trimmed so that the tip would lie at the junction of the superior vena cava and right atrium based on fluoroscopic guidelines.  The peel-away sheath was passed over the guidewire and then the 4-French catheter was deployed through the peel-away sheath.  There was easy blood return and fluoroscopic imaging showed initially the catheter had transited across the mediastinum up the opposite subclavian vein, then it was withdrawn and easily replaced in the superior vena cava.  The catheter insertion site was closed with one buried 5-0 Monocryl stitch and the same 5-0 Monocryl was used to tether the catheter at the exit site until fibrous ingrowth of the attached cuff has occurred.  Heparinized saline solution was used to flush the line.  A sterile occlusive dressing was applied, and the line was prepared for immediate use.  The patient was transported to the recovery room in good condition.  There were no intraoperative complications, and her blood loss was between 5 and 10 mL during the line placement portion of the procedure.
---
DESCRIPTION: Lumbar osteomyelitis and need for durable central intravenous access.  Placement of left subclavian 4-French Broviac catheter.

cardiovascular / pulmonary, lumbar osteomyelitis, central intravenous access, subclavian, osteomyelitis, broviac catheter, catheter, toddler, intravenous,

The given situation involves a medical procedure to place a Broviac catheter in a toddler, which is needed for prolonged intravenous antibiotic therapy due to lumbar osteomyelitis. The stakes can be considered high because this procedure is critical for the child’s ongoing treatment. Additionally, complications during such a procedure can lead to significant problems given the patient's underlying condition and age. However, the operation described was routine with no complications, which slightly reduces the immediate high stakes. Overall, because the procedure is necessary for managing a serious condition, it is high-stakes.


Medical Specialty: Emergency Room Reports
Sample Name: Left Lower Quadrant Pain - ER Visit

HISTORY OF PRESENT ILLNESS:,  The patient is a 26-year-old gravida 2, para 1-0-0-1, at 28-1/7 weeks who presents to the emergency room with left lower quadrant pain, reports no bowel movement in two weeks as well as nausea and vomiting for the last 24 hours or so.  She states that she has not voided in the last 24 hours as well due to pain.  She denies any leaking of fluid, vaginal bleeding, or uterine contractions.  She reports good fetal movement.  She denies any fevers, chills, or burning with urination.,REVIEW OF SYSTEMS: , Positive for back pain in her lower back only.  Her mother reports that she has been eating food without difficulty and that the current nausea and vomiting is much less than when she is not pregnant.  She continues to yell out for requesting pain medication and about how much "it hurts.",PAST MEDICAL HISTORY:,1.  Irritable bowel syndrome.,2.  Urinary tract infections times three.  The patient is unsure if pyelo is present or not.,PAST SURGICAL HISTORY:,  Denies.,ALLERGIES: , No known drug allergies.,MEDICATIONS: , Phenergan and Zofran twice a day.  Macrobid questionable.,GYN: , History of an abnormal Pap, group B within normal limits.  Denies any sexually transmitted diseases.,OB HISTORY: , G1 is a term spontaneous vaginal delivery without complications, now a 6-year-old.  G2 is current.  Gets her care at Lyndhurst.,SOCIAL HISTORY: , Denies tobacco and alcohol use.  She endorses marijuana use and a history of cocaine use five years ago.  Upon review of the Baptist lab systems, the patient has had multiple positive urine drug screens and as recently as February 2008 had a urine drug screen that was positive for benzodiazepines, barbiturates, opiates, and marijuana and as recently as 2005 with cocaine present as well.,PHYSICAL EXAM:,VITAL SIGNS:  Blood pressure 139/82, pulse 89, respirations 20, 98% on room air, 96 degrees Fahrenheit.  Fetal heart tones are 130s with moderate long-term variability.  No paper is available for the fetal heart monitor due to the misorder and audibly sounds reassuring.,GENERAL:  Appears sedated, trashing intermittently, and then falling asleep in mid sentence.,CARDIOVASCULAR:  Regular rate and rhythm.,PULMONARY:  Clear to auscultation bilaterally.,BACK:  Tender to palpation in her lower back bilaterally, but no CVA tenderness.,ABDOMEN:  Tender to palpation in left lower quadrant.  No guarding or rebound.  Normal bowel sounds.,EXTREMITIES:  Scar track marks from bilateral arms.,PELVIC:  External vaginal exam is closed, long, high, and posterior.  Stool was felt in the rectum.,LABS: , White count is 11.1, hemoglobin is 13.5, platelets are 279.  CMP is within normal limits with an AST of 17, ALT of 11, and creatinine of 0.6.  Urinalysis which is supposedly a cath specimen shows a specific gravity of 1.024, greater than 88 ketones, many bacteria, but no white blood cells or nitrites.,ASSESSMENT AND PLAN:  ,The patient is a 26-year-old gravida 2, para 1-0-0-1 at 28-1 weeks with left lower quadrant pain and likely constipation.  I spoke with Dr. X who is the physician on-call tonight, and he requests that she be transferred for continued fetal monitoring and further evaluation of this abdominal pain to Labor and Delivery.  Plans are made for transfer at this time.  This was discussed with Dr. Y who is in agreement with the plan.
---
DESCRIPTION: The patient is a 26-year-old gravida 2, para 1-0-0-1, at 28-1/7 weeks who presents to the emergency room with left lower quadrant pain, reports no bowel movement in two weeks as well as nausea and vomiting for the last 24 hours or so.  She states that she has not voided in the last 24 hours as well due to pain.

The situation involves a pregnant woman at 28 weeks gestation presenting with abdominal pain, persistent constipation, nausea, and vomiting. In the context of emergency medicine, this is a potentially high-stakes situation due to the risk of complications affecting both the mother and the developing fetus. Factors such as the patient's history of drug use, reported fetal movement, and the necessity of further fetal monitoring and evaluation by transferring her to Labor and Delivery add to the complexity and urgency of the case.


Medical Specialty: Surgery
Sample Name: Shunt Revision

TITLE OF OPERATION:,  Bilateral endoscopic proximal shunt revision and a distal shunt revision.,INDICATIONS FOR OPERATION:,  Headaches, full subtemporal site.,PREOPERATIVE DIAGNOSIS: , Slit ventricle syndrome.,POSTOPERATIVE DIAGNOSIS: , Slit ventricle syndrome.,FINDINGS:,  Coaptation of ventricles against proximal end of ventricular catheter.,ANESTHESIA: , General endotracheal tube anesthesia.,DEVICES: , A Codman Hakim programmable valve with Portnoy ventricular catheter, a 0/20 proGAV valve with a shunt assist of 20 cm dual right-angled connector, and a flushing reservoir.,BRIEF NARRATIVE OF OPERATIVE PROCEDURE:,  After satisfactory general endotracheal tube anesthesia was administered, the patient was positioned on the operating table in the prone position with the head held on a soft foam padding.  The occipital area was shaven bilaterally and then the areas of the prior scalp incisions were infiltrated with 0.25% Marcaine with 1:200,000 epinephrine after routine prepping and draping.  Both U-shaped scalp incisions were opened exposing both the left and the right ventricular catheters as well as the old low pressure reservoir, which might have been leading to the coaptation of the ventricles.  The patient also had a right subtemporal depression, which was full preoperatively.  The entire old apparatus was dissected out.  We then cut both the ventricular catheters and secured them with sutures so that __________ could be inserted.  They were both inspected.  No definite debris were seen.  After removing the ventricular catheters, the old tracts were inspected and we could see where there was coaptation of the ventricles against the ventricular catheter.  On the right side, we elected to insert the Portnoy ventricular catheter and on the left a new Bactiseal catheter was inserted underneath the corpus callosum in a different location.  The old valve was dissected out and the proGAV valve with a 2-0 shunt assist was inserted and secured with a 2-0 Ethibond suture.  The proGAV valve was then connected to a Bactiseal distal tubing, which was looped in a cephalad way and then curved towards the left burr hole site and then the Portnoy catheter on the right was secured with a right-angled sleeve and then interposed between it and the left burr hole site with a flushing reservoir.  All connections secured with 2-0 Ethibond suture and a small piece of Bactiseal tubing between the flushing reservoir and the connector, which secured the left Bactiseal tubing to the two other Bactiseal tubings one being the distal Bactiseal tubing going towards the proGAV valve, which was set to an opening pressure of 8 and the other one being the Bactiseal tubing, which was going towards the flushing reservoir.,All the wounds were irrigated out with bacitracin and then closed in a routine manner using Vicryl for the deep layers and Monocryl for the skin, followed by Mastisol and Steri-Strips.  The patient tolerated the procedure well without complications.  CSF was not sent off.
---
DESCRIPTION: Bilateral endoscopic proximal shunt revision and a distal shunt revision.

surgery, codman hakim, portnoy, slit ventricle syndrome, shunt revision, bilateral endoscopic proximal shunt, coaptation of the ventricles, portnoy ventricular catheter, ventricular catheter, progav valve, flushing reservoir, bactiseal tubing, shunt, ventricular, bactiseal

The operation involves complex medical procedures related to shunt systems in a patient with slit ventricle syndrome. It requires precision and accuracy to avoid complications. While routine for experienced surgeons, this type of case has high stakes due to the potential risks associated with brain surgery, such as infections, bleeding, or incorrect placement of shunts, which could severely impact patient outcomes.


Medical Specialty: Surgery
Sample Name: Arthroscopy, Arthrotomy, Bankart lesion repair

TITLE OF OPERATION:,1.  Diagnostic arthroscopy exam under anesthesia, left shoulder.,2.  Debridement of chondral injury, left shoulder.,3.  Debridement, superior glenoid, left shoulder.,4.  Arthrotomy.,5.  Bankart lesion repair.,6.  Capsular shift, left shoulder (Mitek suture anchors; absorbable anchors with nonabsorbable sutures).,INDICATION FOR SURGERY: , The patient was seen multiple times preoperatively and found to have chronic instability of her shoulder.  Risks and benefits of the procedure had been discussed in length including but not exclusive of infection, nerve or artery damage, stiffness, loss of range of motion, incomplete relief of pain, continued instability, recurrent instability, medical complications, surgical complications, and anesthesia complications.  The patient understood and wishes to proceed.,PREOP DIAGNOSIS: , Anterior instability, left shoulder.,POSTOP DIAGNOSES:,1.  Anterior instability, left shoulder.,2.  Grade 4 chondromalacia, 10% humeral head, chondral defect 1 cm squared, left shoulder.,3.  Type 1 superior labrum anterior and posterior lesion, left shoulder.,4.  Anteroinferior glenoid erosions 10% bony surface, left shoulder.,5.  Bankart lesion, left shoulder.,PROCEDURE: , The patient was placed in a supine position and both shoulders examined systematically.  She had full range of motion with no joint adhesions.  She had equal range of motion bilaterally.  She had Hawkins 2 anteriorly and posteriorly in both shoulders with a grade 1 sulcus sign in both shoulders.  This was the same when the arm was in neutral or in external rotation.  The patient was then turned to right lateral decubitus position, axillary roll was placed, and beanbag was inflated.  Peroneal nerve was well protected.  All bony prominences were well protected.,The left upper extremity was then prepped and draped in the usual sterile fashion.  The patient was given antibiotics well before the start of the procedure to decrease the risk of infection.  The arm was placed in a arm holder with 10 pounds of traction.  A posterior portal was created in the usual manner by isolating gently with the spinal needle, it was insufflated with 30 cubic centimeters of saline.  A small incision was made after infiltrating the skin with Marcaine and epinephrine.  The scope was introduced into the shoulder with no difficulty.  It was then examined systematically.  The patient did have diffuse synovitis throughout her shoulder.  Her posterior humeral head showed an enlarged bold spot with some other areas of chondromalacia on the posterior head.  She also had an area 1 cm in diameter, which was on more central portion of the head and more inferiorly which appeared to be more of an impaction-type injury.  This had some portions of fibrillated and loose cartilage, hanging from the edges.  These were later debrided, but the dissection was proximally 10 to 15% of the humeral surface.,The biceps tendon appeared to be normal.  The supraspinatus, infraspinatus tendons were normal.  The inferior pouch was normal with no capsular tearing and no HAGL lesions.  The posteroinferior labrum was normal as well as the posterosuperior labrum.  There was some fraying in the posterosuperior labrum, which was later debrided.  It was found essentially to be a type 1 lesion anteriorly and superiorly.  The anterosuperior labrum appeared to be detached, which appeared to be more consistent with a sublabral hole.  The middle glenohumeral ligament was present as an entire sheath, but attach to the labrum.  The labrum did appeared to be detached from the anterior glenoid from the 11 o'clock position all the way down to the 6 o'clock position.  The biceps anchor itself was later probed and found to be stable and normal.  The subscapularis tendon was normal.  The anterior band of the glenohumeral ligament was present, but it was clearly avulsed off the glenoid.  There was some suggestion of anteroinferior bony erosions, which was later substantiated when the shoulder was opened.  The patient was missing about 10 to 15% of her anteroinferior glenoid rim.  The patient had a positive drive-through sign.,The arm was then moved to lateral and placed through range of motion.  There was contact of the rotator cuff to the superior glenoid in flexion at 115 degrees, maximum flexion was 150 degrees.  The arm abducted and externally rotated.  There was contact to the rotator cuff with posterosuperior labrum.  This occurred with the arm position of 90 degrees with abduction at 55 degrees of external rotation.  It should be noted that the maximum abduction is 150 degrees and with the arm abducted 90 degrees, maximum external rotation was 95 degrees.  The patient did have a positive relocation maneuver.  The posterior labrum did appear to tilt-off, but did not appear to peel off.,The arm was then placed back in the arm holder.  Anterior portal was created with Wissinger rod.  A blue cannula was inserted into the shoulder without difficulty.  Shaver was introduced in the labrum.  Also the area of chondromalacia as mentioned above was debrided.  The labrum was found to be stable with only a type 1 SLAP lesion, and there was no evidence as there was really a type 2 SLAP lesion.  The instruments were then removed along with excess fluid.  The posterior portals were closed with single 4-0 nylon suture.  The anterior portal was left open.  The patient was then placed in a supine position, and the extremity was reprepped and draped in anticipation of performing open capsular shift.,The patient's anterior incision made just lateral to the coracoid in the skin line.  Mediolateral skin flaps were developed, and cephalic vein was identified and protected throughout the case.  The interval was developed down the clavipectoral fascia.  The conjoined tendon was retracted medially and the deltoid laterally.  The patient's subscapularis was intact, and the subscapularis split was then made between the upper one half and lower one half in line with muscle fibers.  The capsule could easily be detached from the muscle, and the interval developed very easily.  A retractor was placed inferiorly to protect the axillary nerve.  Then Gelpi retractor was used to hold the subscapularis split open.,Next, an arthrotomy was made down at the 9 o'clock position.  The labrum was identified and found to be attached all the way down to 6 o'clock position.  The inferior flap was then created in a usual manner and tied with a 0 Vicryl suture.  The patient's glenoid rim did have some erosion as mentioned above with some bone loss and flattening.  This was debrided with the soft tissue.  Three Mitek suture anchors were then placed into the glenoid rim right at the margin of articular cartilage to the scapular neck.  These were absorbable anchors with nonabsorbable sutures.  They had excellent fixation once they had been placed.,Next, the capsular shift and Bankart repair were performed in the usual manner with the number 2 Ti-Cron sutures as an outside in and then inside out technique.  This brought the capsule right up to the edge of the glenoid rim.  With the arm in internal rotation and posterior pressure on the head, the capsule was then secured to the rim with no difficulty under direct visualization.  The capsule did come right up into the joint as expected with this type of repair.  The superior flap was then closed, the inferior flap over the superior anchor.  The interval between two flaps was closed with multiple number 2 Ti-Cron sutures.  Once this has been completed, there was no tension on the repair with the arm to side until 10 degrees of external rotation was reached.  The arm abducted 90 degrees.  There was tension on the repair until 20 degrees of external rotation reached.,The wound was thoroughly irrigated throughout with antibiotic-impregnated irrigation.  The subscapularis split was closed with interrupted 0 Vicryl sutures.  The deep subcutaneous tissues were closed with interrupted 0 Vicryl sutures.  The superficial subcutaneous tissues were closed with number 2-0 Vicryl sutures.  The skin was closed with 4-0 subcuticular Prolene, reinforced with Steri-Strips.  A sterile bandage was applied along with a cold therapy device and a shoulder immobilizer.  The patient was sent to the recovery room in stable and satisfactory condition.
---
DESCRIPTION: Diagnostic arthroscopy exam under anesthesia, left shoulder.  Debridement of chondral injury, left shoulder.  Debridement, superior glenoid, left shoulder.  Arthrotomy.  Bankart lesion repair.  Capsular shift, left shoulder (Mitek suture anchors; absorbable anchors with nonabsorbable sutures).

surgery, diagnostic arthroscopy, chondral injury, debridement, superior glenoid, arthrotomy, bankart lesion, capsular shift, mitek suture, absorbable anchors, anterior instability, chondromalacia, superior labrum, glenoid erosion, glenoid rim, external rotation, glenoid, labrum, shoulder, arthroscopy,

The described procedure involves multiple complex surgical operations on the shoulder, addressing issues such as a Bankart lesion and anterior instability. These are significant surgical interventions intended to address chronic instability and prevent further damage. Surgery inherently carries risks, such as infection, nerve or artery damage, and complications from anesthesia. Additionally, this specific case involves intricate work on the shoulder, a joint critical for daily movement and functionality. The details indicate that this is a specialized surgery requiring precision and skill, as well as posing significant risks to the patient's health and mobility if complications arise. Therefore, given the potential consequences and the importance of the operation to the patient’s quality of life, I would classify this situation as high-stakes.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Bronchoscopy & Lobectomy

PREOPERATIVE DIAGNOSIS:  ,Carcinoma of the left upper lobe.,PROCEDURES PERFORMED:,1.  Bronchoscopy with aspiration.,2.  Left upper lobectomy.,PROCEDURE DETAILS:  ,With patient in supine position under general anesthesia with endotracheal tube in place, the flexible bronchoscope was then placed down through the endotracheal tube to examine the carina.  The carina was in the midline and sharp.  Moving directly to the right side, the right upper and middle lower lobes were examined and found to be free of obstructions.  Aspiration was carried out for backlog ________ examination.  We then moved to left side, left upper lobe.  There was a tumor mass located in the lingula of the left lobe and left lower lobe found free of obstruction.  No anatomic lesions were demonstrated.  The patient was prepared for left thoracotomy rotated to his right side with a double lumen endotracheal tube in place with an NG tube and a Foley catheter.  After proper position, utilizing Betadine solution, they were draped.  A posterolateral left thoracotomy incision was performed.  Hemostasis was secured with electrocoagulation.  The chest wall muscle was then divided over the sixth rib.  The periosteum of the sixth rib was then removed superiorly and the pleural cavity was entered carefully.  At this time, the mass was felt in the left upper lobe, which measures greater than 3 cm by palpation.  We examined the superior mediastinum.  No lymph nodes were demonstrated as well as in the anterior mediastinum.  Direction was then moved to the fascia where by utilizing sharp and blunt dissection, lingual artery was separated into the left upper lobe.  Casual dissection was carried out with superior segmental arteries and left lower lobe was examined.,Dissection was carried out around the pulmonary artery thus exposing the posterior artery to the left upper lobe.  Direction was carried out to the superior pulmonary vein and utilizing sharp and blunt dissection the entire superior pulmonary vein was separated from the surrounding tissue.  From the top side, the bronchus was then separated away from the pulmonary artery anteriorly, thus exposing the apical posterior artery, which was short.  Tumor mass was close to the artery at this time.  We then directed ourselves once again to the lingual artery which was doubly ligated and cut free.  The posterior artery of the superior branch was doubly ligated and cut free also.  At this time, the bronchus of the left upper lobe was encountered in the fissure on palpation to separate the upper lobe bronchus from lower lobe bronchus and the area was accomplished.  We then moved anteriorly to doubly ligate the pulmonary vein using #00 silk sutures for ligation and a transection #00 silk suture was used to fixate the vein.  Using sharp and blunt dissection, the bronchus through the left upper lobe was freed proximal.  Using the TA 50, the bronchus was then cut free allowing the lung to fall superiorly at which time direction was carried out to the pulmonary artery where the tumor was in close proximity at this time.  A Potts clamp arterial was then placed over the artery and shaving off the tumor and the apical posterior artery was then accomplished.  The anterior artery was seen in the clamp also and was separated and ligated and separated.  At this time, the entire tumor in the left upper lobe was then removed.  ,Direction was carried to the suture where #000 silk was used as a running suture over the pulmonary artery and was here doubly run and tied in place.  The clamp was then removed.  No bleeding was seen at this time.  Lymph nodes were then removed from the sump of the separation between the upper lobe and the lower lobe and sent for separate pathology.  We then carried out incision in the inferior pulmonary ligament up to the pulmonary vein allowing the lung to reexpand to its normal position.  At this time, two chest tubes #28 and #32 were placed anteriorly and posteriorly to fixate the skin using raw silk suture.  The chest cavity was then closed.  After reexamination, no bleeding was seen with three pericostal sutures of #1 chromic double strength.  A #2-0 Polydek was then used to close the chest wall muscle the anterior as well as latissimus dorsi #000 chromic subcutaneous tissue skin clips to the skin.  The chest tubes were attached to the Pleur-Evac drainage and placed on suction at this time.  The patient was extubated in the room without difficulty and sent to Recovery in satisfactory.
---
DESCRIPTION: Bronchoscopy with aspiration and left upper lobectomy.  Carcinoma of the left upper lobe.

cardiovascular / pulmonary, ng tube, chest tubes, endotracheal tube, pulmonary vein, artery, aspiration, lobectomy, bronchoscopy, tumor, vein, bronchus, pulmonary,

The provided scenario details a complex surgical procedure involving a bronchoscopy and lobectomy to treat a carcinoma in the left upper lobe of the lung. This procedure is significant and involves numerous steps and considerations, including the handling of tumor masses, arteries, veins, and bronchi. The stakes are high because it involves critical structures within the thoracic cavity, and any complications could be life-threatening. Successful removal of the tumor and management of potential complications is crucial for the patient's prognosis. Therefore, the situation is high-stakes in nature due to the potential risk to the patient’s life and the complexity of the surgery.


Medical Specialty: Surgery
Sample Name: Bbunionectomy & Metatarsal Osteotomy

PREOPERATIVE DIAGNOSIS:  ,Tailor's bunion and neuroma of the second and third interspace of the left foot.,POSTOPERATIVE DIAGNOSIS:, Tailor's bunion and neuroma of the second and third interspace, left foot.,PROCEDURE PERFORMED:,1.  Tailor's bunionectomy with metatarsal osteotomy of the left fifth metatarsal.,2.  Excision of nerve lesion with implantation of the muscle belly of the left second interspace.,3.  Excision of nerve lesion in the left third interspace.,ANESTHESIA:  ,Monitored IV sedation with local.,HISTORY:  ,This is a 37-year-old female who presents to ABCD's preoperative holding area, n.p.o. since mid night, last night for surgery of her painful left second and third interspaces and her left fifth metatarsal.  The patient has attempted conservative correction and injections with minimal improvement.  The patient desires surgical correction at this time.  The patient states that her pain has been increasingly worsening with activity and with time and it is currently difficult for her to ambulate and wear shoes.  At this time, the patient desires surgical intervention and correction.  The risks versus benefits of the procedure have been explained to the patient in detail by Dr. X and consent was obtained.,PROCEDURE IN DETAIL: , After an IV was instituted by the Department of Anesthesia in the preoperative holding area, the patient was taken to the Operating Suite via cart and placed on the operating table in the supine position.  A safety strap was placed across her waist for protection.,Next, a pneumatic ankle tourniquet was applied around her left ankle over copious amounts of Webril for the patient's protection.  After adequate IV sedation was administered by the Department of Anesthesia, a total of 20 cc of a mixture of 4.5 cc of 1% lidocaine plain, 4.5 cc of 0.5% Marcaine plain, and 1 cc of Solu-Medrol per 10 cc dose was administered to the patient for local anesthesia.  The foot was then prepped and draped in the usual sterile orthopedic manner.  The foot was then elevated and a tourniquet was then placed at 230 mmHg after applying Esmarch bandage.  The foot was then lowered down the operative field and sterile stockinet was draped.  The stockinet was then reflected.  Attention was then directed to the second intermetatarsal interspace.  After testing the anesthesia, a 4 cm incision was placed using a #10 blade over the dorsal surface of the foot in the second intermetatarsal space beginning from proximal third of the metatarsals distally to and beyond the metatarsal head.  Then, using #15 blade the incision was deepened through the skin into the subcutaneous tissue.  Care was taken to identify and avoid or to cauterize any local encountered vascular structures.  Incision was deepened using the combination of blunt and dull dissection using Mayo scissors, hemostat, and a #15 blade.  The incision was deepened distally down to the level of the deep transverse metatarsal ligament which was reflected and exposure of the intermetatarsal space was appreciated.  The individual branches of the plantar digital nerve were identified extending into the second and third digits plantarly.  These endings were dissected distally and cut at their most distal portions.  Following this, the nerve was dissected proximally into the common nerve and dissected proximally into the proximal portion of the intermetatarsal space.  Using careful meticulous dissection, there was noted to a be a enlarged bulbous mass of fibers and nerve tissue embedded with the adipose tissue.  This was also cut and removed.  The proximal portion of the nerve stump was identified and care was taken to suture this into the lumbrical muscle to leave no free nerve ending exposed.  Following this, the interspace was irrigated with copious amounts of sterile saline and interspace explored for any other portions of nerve which may been missed on the previous dissection.  It was noted that no other portions of the nerve were detectable and the proximal free nerve ending was embedded and found to be ________ the lumbrical muscle belly.  Following this, the interspace was packed using iodoform gauze packing and was closed in layers with the packing extruding from the wound.  Attention was then directed to the third interspace where in a manner as mentioned before.  A dorsal linear incision which measured 5 cm was made over the third interspace extending from the proximal portion of the metatarsal distally to the metatarsal head.  Like before, using a combination of blunt and dull dissection, with sharp dissection the incision was deepened down with care taken to cauterize all retracting vascular structures which were encountered.,The incision was deepened down to the level of the subcutaneous tissue and then down deeper to the interspace of the third and fourth metatarsal.  The dissection was deepened distally down to the level of the transverse intermetatarsal ligament, where upon this was reflected and the nerve fibers to the third and fourth digit plantarly were identified.  These were once again dissected distally out and transected at their most distal portions.  Care was then taken to dissect the nerve proximally into the proximal metatarsal region.  No other branches of the nerve were identified and the nerve in its entirety along with fibrous tissue encountered in the area was removed.  The proximal portion of the nerve which remained was not large enough to suture into lumbrical muscle as was done in the previous interspace.  Half of the nerve was transected proximally as was feasible and no exposed ending was noted.  Incision was then flushed and irrigated using sterile saline.  Following this, the incision wound was packed with iodoform gauze packed and closed in layers using as before #4-0 Vicryl and #4-0 nylon suture.,Following this, attention was directed to the fifth metatarsal head where a lateral 4 cm incision was placed along the lateral distal shaft and head of the fifth metatarsal using a fresh #10 blade.  The incision was then deepened using #15 blade down to the level of the subcutaneous tissue.  Care was taken to reflect any neurovascular structures which were encountered.  Following this the incision was deepened down to the level of the periosteum and periosteum was reflected, using the sharp dissection, to expose the head of the metatarsal along with the neck region.  After adequate exposure of the fifth metatarsal head was achieved, an oblique incision directed from distal lateral to proximal medial in a sagittal plane was performed and the head of the fifth metatarsal was shifted medially.  Following this, an OrthoSorb pin was retrograded through the fifth metatarsal head into the neck of the fifth metatarsal and was cut off first with the lateral surfaces of bone.  OrthoSorb pin was noted to be intact and the fifth metatarsal head was in good alignment and position.  Following this, the sagittal saw and the #138 blade were used to provide rasping and smoothing of the sharp acute edges of bone laterally.  Following this, the periosteum was closed using #4-0 Vicryl and the skin was closed in layers using #4-0 Vicryl and closed with running subcuticular #4-0 Monocryl suture.  Upon completion of this, the foot was noted to be in good position with good visual alignment of the fifth metatarsal head and digit.  The incisions in foot were then ________ draped in the normal manner using Owen silk, 4 x 4s, Kling, and Kerlix and covered with Coban bandage.  The tourniquet was then deflated with the total tourniquet time of 103 minutes at 230 mmHg and immediate hyperemia was noted to end digits one through five of the left foot.,The patient was then transferred to the cart and was escorted to the Postanesthesia Care Unit with vital signs stable and vascular status intact.  The patient tolerated the procedure well without any complications.  The patient was then given prescriptions for Vicoprofen #30 and Augmentin #14 to be taken twice daily.  The patient was instructed to followup with Dr. X after the weekend on Tuesday in his office.  The patient also given postoperative instructions and was placed in a postoperative shoe and instructed to limit weightbearing to the heel only, ice and elevate her foot 20 minutes every hour as tolerated.  The patient also instructed to take her medications and prescriptions as directed.  She was given the emergency contact numbers.  Postoperative x-rays were taken and the patient was discharged home in stable condition upon conclusion of this.
---
DESCRIPTION: Tailor's bunionectomy with metatarsal osteotomy of the left fifth metatarsal.  Excision of nerve lesion with implantation of the muscle belly of the left second interspace.  Excision of nerve lesion in the left third interspace.

surgery, tailor's bunion, neuroma, nerve lesion, interspace, metatarsal, osteotomy, metatarsal osteotomy, metatarsal head, foot, distally, head, incision, nerve, intermetatarsal, portions,

The situation involves a detailed surgical procedure for a patient with a Tailor's bunion and neuromas. Surgery, especially involving nerve excisions and metatarsal osteotomy, is inherently a high-stakes situation due to risks such as infection, nerve damage, or complications from anesthesia. Though this is a planned and routine procedure for this condition, any surgery carries risks that make it high-stakes, particularly because it's performed on an ambulatory adult who needs detailed postoperative care.


Medical Specialty: Surgery
Sample Name: Kyphoplasty

PRE-OP DIAGNOSIS:,  Osteoporosis, pathologic fractures T12- L2 with severe kyphosis.,POST-OP DIAGNOSIS:,  Osteoporosis, pathologic fractures T12- L2 with severe kyphosis.,PROCEDURE:,1.  KYPHON Balloon Kyphoplasty at T12 and L1evels Insertion of KYPHON HV-R bone cement under low pressure at T12 and L1 levels.,2.  Bone biopsy (medically necessary).,ANESTHESIA:, General,COMPLICATIONS:, None,BLOOD LOSS:, Minimal,INDICATIONS:,  Mrs. Smith is a 75-year-old female who has had severe back pain that began approximately three months ago and is debilitating.  She has been unresponsive to nonoperative treatment modalities including bed rest and analgesics.  She presents with and is on medication therapy for COPD, diabetes and hypertension (other co-morbidities may be present upon admission and should be documented in the operative note).,Radiographic imaging including MRI confirms multiple compression fractures of the thoracolumbar spine including T12, L1 and L2.  In addition to the fractures, she presents with kyphotic posture.  Films on 1/04 demonstrated L1 and L2 osteoporotic fractures.  Films on 2/04 demonstrated increased loss of height at L1.  Films on 3/04 demonstrated a new compression fracture at T12 and further collapse of L1.  The L2 fracture is documented on radiographic studies as being chronic and a year or more old.  The T12 fracture has the most significant kyphotic deformity.  Based on these findings, we have decided to perform KYPHON Balloon Kyphoplasty on the L1 and T12 fractures.,PROCEDURE:,  The patient was brought to the operating room/radiology suite and general anesthesia/local sedation with endotracheal intubation was performed.  The patient was positioned prone on the Jackson table.  The back was prepped and draped.  The image intensifier (C-arm) was brought into position and the T12 pedicles were identified and marked with a skin marker.  In view of the collapse of T12, a transpedicular approach to the vertebral body was appropriate.  An 11-gauge needle was advanced through the T12 pedicle to the junction of the pedicle and vertebral body on the right side.  Positioning was confirmed on the AP and lateral plane.  Following satisfactory placement of the needle, the stylet was removed.  A guide pin was inserted through the 11g to a point 3mm from the anterior cortex.  AP and lateral images were taken to verify position and trajectory.  Alongside of the guide pin a 1-cm paramedian incision was made.  The needle was then removed leaving the guide pin in place.  The osteointroducer was placed over the guide pin and advanced through the pedicle.  Once I was at the junction of the pedicle and the vertebral body, a lateral image was taken to insure that the cannula was positioned approximately 1cm past the vertebral body wall.  Through the cannula, a drill was advanced into the vertebral body under fluoroscopic guidance toward the anterior cortex, creating a channel.  The anterior cortex was probed with the guide pin to ensure no perforations in the anterior cortex.  After completing the entry into the vertebral body, a 15 mm inflatable bone tamp was inserted through the cannula and advanced under fluoroscopic guidance into the vertebral body near the anterior cortex.  The radiopaque marker bands on the bone tamp were identified using AP and lateral images.  The above sequence of instrument placement was then repeated on the left side of the T12 vertebral body.  Once both bone tamps were in position, they were inflated to 0.5 cc and 50 psi.  Expansion of the bone tamps was done sequentially in increments of 0.25 to 0.5 cc of contrast, with careful attention being paid to the inflation pressures and balloon position.  The inflation was monitored with AP and lateral imaging.  The final balloon volume was 3.5 cc on the right side and 3 cc on the left.  There was no breach of the lateral wall or anterior cortex of the vertebral body.  Direct reduction of the fracture was achieved, end plate movement was noted and approximately 5 mm of height restoration was achieved.  Under fluoroscopic imaging, and the use of the bone void fillers, internal fixation was achieved through a low-pressure injection of KYPHON HV-R bone cement.  The cavity was filled with a total volume of 3.5 cc on the right side and 3 cc on the left side.  Once the bone cement had hardened, the cannulas were then removed.,At this time, we proceeded to perform a balloon kyphoplasty at L1 using the same sequence of steps as on T12.  An entry needle was placed bilaterally through the pedicle into the vertebral body, a cortical window was created, inflation of the bone tamps directly reduced the fracture, the bone tamps were removed, and internal fixation by bone void filler insertion was achieved.  Throughout the procedure, AP and lateral imaging monitored positioning.,Post-procedure, all incisions were closed with sutures.  The patient was kept in the prone position for approximately 10 minutes post cement injection.  She was then turned supine, monitored briefly and returned to the floor.  She was moving both her lower extremities at this time.,Throughout the procedure, there were no intraoperative complications.  Estimated blood loss was minimal.
---
DESCRIPTION: KYPHON Balloon Kyphoplasty at T12 and L1evels Insertion of KYPHON HV-R bone cement under low pressure at T12 and L1 levels and bone biopsy.

surgery, osteoporosis, pathologic fractures, kyphosis, bone cement, balloon kyphoplasty, kyphon balloon kyphoplasty, bone biopsy, kyphon, insertion of kyphon, ap and lateral, vertebral body, kyphon balloon, anterior cortex, vertebral, body, fractures, insertion, bone, kyphoplasty, guide, balloon, pedicles, cortex, positioned, therapy

This is a surgical procedure involving a balloon kyphoplasty, which is performed to address vertebral compression fractures often due to osteoporosis. The procedure involves significant technical aspects, uses general anesthesia, and aims to relieve debilitating pain and restore functionality, particularly in an elderly patient with multiple comorbidities. While the procedure itself is relatively common and usually safe, the high stakes come from the patient's age, the severity of her condition, and the potential impact on her quality of life. The presence of co-morbid conditions like COPD, diabetes, and hypertension also increases the stakes, despite the fact that no complications arose during the procedure.


Medical Specialty: Emergency Room Reports
Sample Name: Penile Injury

REASON FOR ADMISSION:,  Penile injury and continuous bleeding from a penile laceration.,HISTORY OF PRESENT ILLNESS:,  The patient is an 18-year-old detainee who was brought by police officers because of a penile injury and bleeding.  He is otherwise healthy.  He tried to insert a marble in his penis four days ago.  He told me that he grabbed the skin on the top of the penis and moved it away from the penis shaft and then using a toothbrush that he made in to a knife object he pierced the skin through from both sides and then kept moving the toothbrush to dilate and make a way for the marble.  Then he inserted a heart-shaped marble in one of the puncture wounds and inserted it under the skin and kept it there.  He was not significantly bleeding and essentially the bleeding stopped from both puncture wounds that he has.  Then today four days after that procedure, he was taking a bath today and he thinks because of the weight he felt a gush in his pants and he looked and he saw the bleeding come out.  He was bleeding so much that he started dripping to the sides of his legs.  So, he was brought to the hospital.  Actually after being seen by two nurses at the facility where he was at the detention center where he was at and they actually did the dressing twice and it was twice soaked with blood.  He came here and was continuously bleeding from that area that we had to change the dressing twice and he is actually still bleeding especially from one of the laceration, the one on the right side of the penis.  The marble also still can be felt underneath the skin.  There is no urethral bleeding.  He did urinate today without difficulty, without hematuria or dysuria.  There is pain in the lacerations.  No erythema in the skin or swelling in the penis and no other injuries.  He did this procedure for sexual pleasure as he said.,PAST MEDICAL HISTORY: , Unremarkable.,PAST SURGICAL HISTORY:  ,Tonsillectomy.,MEDICATION: , He took only ibuprofen.  No regular medication.,ALLERGIES: , None.,SOCIAL HISTORY:  ,He has been in detention for two months for immigration problems.  No drugs.  No alcohol.  No smoking.  He used to work in fast food chain.,FAMILY HISTORY: , Noncontributory to this illness.,REVIEW OF SYSTEMS: , Aside from the pain in the penis and continuous bleeding, he is basically asymptomatic and review of systems is unremarkable.,PHYSICAL EXAMINATION:,GENERAL:  The patient is a young Hispanic male, lying in bed, appear comfortable in no apparent distress.,VITAL SIGNS:  Temperature 97.8, heart rate 99, respiratory rate 20, blood pressure 142/100, and saturation is 98% on room air.,ENT:  Sclerae nonicteric.  Pupils reactive to light.  Nostrils are normal.  Oral cavity is clear.,NECK:  Supple.  Trachea midline.  No JVD.,LUNGS:  Clear to auscultation bilaterally.,HEART:  Normal S1 and S2.  No murmurs or gallops.,ABDOMEN:  Soft, nontender, and nondistended.  Positive bowel sounds.,EXTREMITIES:  Pulses strong bilaterally.  No edema.,GENITAL:  Testicles appear normal.  The penis shaft has two lacerations on both sides, one of them is bleeding.  They measure about 5 to 6 mm on the right side, about 3 or 4 mm on the left side.  The one on the right side is bleeding much more than the other one.  There is a marble that can be felt and it is freely mobile underneath the skin of the dorsum of the penis.  There is no bleeding from the meatus or discharge and no other injuries were seen by inspection.,LABORATORY DATA:,  White count 11.1, hemoglobin 14.5, hematocrit 43.5, and platelets 303,000.  Coags unremarkable.  Glucose 106, creatinine 0.8, sodium 141, potassium 4, and calcium 9.7.  Urinalysis unremarkable.,IMPRESSION: , The patient with a penile laceration that is continuously bleeding from inserting a marble four days ago, which is still underneath the skin of the shaft of the penis.  No other injuries that can be seen and no other evidence of secondary bacterial infection at this time.  The patient is currently refusing removal of the marble and insisting on just repairing the laceration and he is having discussion with Dr. X.,PLAN:,1.  The patient will be admitted to the hospital and will follow Dr. X's recommendation.,2.  The patient was offered a repair of those lacerations, to stop the bleeding as well as the removal of the marble and he is currently considering that and discussing that with Dr. X.,3.  Prophylactic antibiotics to prevent infection.,4.  He has mild hypertension, which is likely due to stress and pain and also the leukocytosis probably can be explained by that.  This will be monitored.,5.  Monitor H&H to determine if he needs any transfusion at this time.  He does not need that.,6.  IV fluid for hydration and volume resuscitation at this time.,7.  Pain management.,8.  Topical care for the wound VAC after repair.,Time spent in evaluation and management of this patient including discussions about this procedure and the harm that can happen if he chooses to keep the penis including permanent damage and infection to the penis was 65 minutes.,I had clearly explained to the patient in detail about the possibility of permanent penile damage that could affect erection and future sexual functioning as well as significant infection if a foreign object was retained in the penis under the skin and he verbalized understanding of this.
---
DESCRIPTION: Penile injury and continuous bleeding from a penile laceration.

The situation involves a young patient with a continuous bleeding penile laceration caused by a self-inflicted injury with a foreign object. The medical team is concerned about potential infections, further bleeding, and possible permanent damage to the penile tissue which could affect sexual function. The patient is refusing immediate removal of the object despite being informed of the risks, which includes infection and permanent damage. Thus, the stakes are high as there could be significant long-term health consequences if not treated properly and urgently. Moreover, the psychological aspects of discussing bodily harm and the patient's current setting as a detainee may contribute to the overall complexity and urgency of the issue.


Medical Specialty: Surgery
Sample Name: Circumcision - 5

PROCEDURES:,1.  Release of ventral chordee.,2.  Circumcision.,3.  Repair of partial duplication of urethral meatus.,INDICATIONS: , The patient is an 11-month-old baby boy who presented for evaluation of a duplicated urethral meatus as well as ventral chordee and dorsal prepuce hooding.  He is here electively for surgical correction.,DESCRIPTION OF PROCEDURE: , The patient was brought back into operating room 35.  After successful induction of general endotracheal anesthetic, giving the patient, preoperative antibiotics and after completing a preoperative time out, the patient was prepped and draped in the usual sterile fashion.,A holding stitch was placed in the glans penis.  At this point, we probed both urethral meatus.  Using the Crede maneuver, we could see urine clearly coming out of the lower, the more ventral meatus.  At this point, we cannulated this with a 6-French hypospadias catheter.  We attempted to cannulate the dorsal opening, however, we were unsuccessful.  We then attempted to place lacrimal probes and were also unsuccessful indicating this was incomplete duplication.  At this point, we identified the band connecting both the urethral meatus and incised it with tenotomy scissors.  We sutured both meatus together such that there was one meatus at the normal position at the tip of the glans.,At this point, we made a circumcising incision around the penis and degloved the penis in its entirety relieving all chordee.  Once all the chordee had been adequately released, we turned our attention to the circumcision.  Excessive dorsal foreskin was removed from the skin and glans.  Mucosal cuts were reapproximated with interrupted 5-0 chromic suture.  Dermabond was placed over this and bacitracin was placed on this once dry.  This ended the procedure.  ,DRAINS:,  None.,ESTIMATED BLOOD LOSS: , Minimal.,URINE OUTPUT:  ,Unrecorded.,COMPLICATIONS: , None apparent.,DISPOSITION:  ,The patient will now go under the care of Dr. XYZ, Plastic Surgery, for excision of scalp hemangioma.
---
DESCRIPTION: Release of ventral chordee, circumcision, and repair of partial duplication of urethral meatus.

surgery, release of ventral chordee, repair of partial duplication, partial duplication, ventral chordee, urethral meatus, glans, penis, circumcision, ventral, chordee, urethral, meatus,

The procedure involves surgery on an 11-month-old baby to correct anatomical abnormalities including ventral chordee, duplication of the urethral meatus, and dorsal prepuce hooding. While the procedure is elective, it involves general anesthesia and delicate surgical work on an infant, which inherently carries some risks due to the age and vulnerability of the patient. However, the procedure is described as straightforward with minimal blood loss and no apparent complications. It is not a life-threatening emergency but still requires surgical precision and post-operative care.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Cardiac Consultation - 4

REASON FOR CONSULTATION:,  Cardiac evaluation.,HISTORY: , This is a 42-year old Caucasian male with no previous history of hypertension, diabetes mellitus, rheumatic fever, rheumatic heart disease, or gout.  Patient used to take medicine for hyperlipidemia and then that was stopped.  He used to live in Canada and he moved to Houston four months ago.  He started complaining of right-sided upper chest pain, starts at the right neck and goes down to the right side.  It lasts around 10-15 minutes at times.  It is 5/10 in quality.  It is not associated with shortness of breath, nausea, vomiting, or sweating.  It is not also associated with food.  He denies exertional chest pain, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, or pedal edema.  No palpitations, syncope or presyncope.  He said he has been having little cough at night and he went to see an allergy doctor who prescribed several medications for him and told him that he has asthma.  No fever, chills, cough, hemoptysis, hematemesis or hematochezia.  His EKG shows normal sinus rhythm, normal EKG.,PAST MEDICAL HISTORY:,  Unremarkable, except for hyperlipidemia.,SOCIAL HISTORY: , He said he quit smoking 20 years ago and does not drink alcohol.,FAMILY HISTORY: , Positive for high blood pressure and heart disease.  His father died in his 50s with an acute myocardial infarction.,MEDICATION:,  Ranitidine 300 mg daily, Flonase 50 mcg nasal spray as needed, Allegra 100 mg daily, Advair 500/50 bid.,ALLERGIES:,  No known allergies.,REVIEW OF SYSTEMS:,  As mentioned above,EXAMINATION:,  This is a 42-year old male awake, alert, and oriented x3 in no acute distress.,Wt:  238
---
DESCRIPTION: Patient with right-sided chest pain, borderline elevated high blood pressure, history of hyperlipidemia, and obesity.

The situation involves a 42-year-old male with chest pain and a family history of heart disease, specifically an acute myocardial infarction. While the pain isn't currently associated with more alarming symptoms such as shortness of breath or sweating, the patient's family history and previous diagnosis of hyperlipidemia can present a risk of cardiac issues. However, there is no immediate life-threatening condition disclosed in the information, the patient is stable, and there is no acute distress reported. This suggests the situation is not extremely high-stakes but still significant due to possible cardiovascular implications.


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

Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Bronchoscopy

PREOPERATIVE DIAGNOSIS: , Atelectasis.,POSTOPERATIVE DIAGNOSIS: , Mucous plugging.,PROCEDURE PERFORMED: , Bronchoscopy.,ANESTHESIA: , Lidocaine topical 2%, Versed 3 mg IV.  Conscious sedation.,PROCEDURE: , At bedside, a bronchoscope was passed down the tracheostomy tube under monitoring.  The main carina was visualized.  The trachea was free of any secretions.  The right upper lobe, middle and lower lobes appeared to have some mucoid secretions but minimal and with some erythema.  Left mainstem appeared patent.  Left lower lobe had slight plugging in the left base, but much better that previous bronchoscopy findings.  The area was lavaged with some saline and cleared.  The patient tolerated the procedure well.
---
DESCRIPTION: Bronchoscopy.  Atelectasis and mucous plugging.

The procedure described is a bronchoscopy, which is generally considered a routine medical procedure used for diagnosing and sometimes treating conditions related to the airways, such as atelectasis and mucous plugging. While there are potential risks associated with any medical procedure, bronchoscopy is non-surgical and minimally invasive. The situation does not involve immediate life-threatening conditions or complex surgical interventions, hence it is not extremely high-stakes. However, it still requires careful handling and expertise, particularly because it involves the respiratory system. Therefore, the stakes are moderate.


Medical Specialty: Surgery
Sample Name: Bronchoscopy - 3

PROCEDURE: , Fiberoptic bronchoscopy.,PREOPERATIVE DIAGNOSIS:,  Right lung atelectasis.,POSTOPERATIVE DIAGNOSIS:,  Extensive mucus plugging in right main stem bronchus.,PROCEDURE IN DETAIL:,  Fiberoptic bronchoscopy was carried out at the bedside in the medical ICU after Versed 0.5 mg intravenously given in 2 aliquots.  The patient was breathing supplemental nasal and mask oxygen throughout the procedure.  Saturations and vital signs remained stable throughout.  A flexible fiberoptic bronchoscope was passed through the right naris.  The vocal cords were visualized.  Secretions in the larynx were as aspirated.  As before, he had a mucocele at the right anterior commissure that did not obstruct the glottic opening.  The ports were anesthetized and the trachea entered.  There was no cough reflex helping explain the propensity to aspiration and mucus plugging.  Tracheal secretions were aspirated.  The main carinae were sharp.  However, there were thick, sticky, grey secretions filling the right mainstem bronchus up to the level of the carina.  This was gradually lavaged clear.  Saline and Mucomyst solution were used to help dislodge remaining plugs.  The airways appeared slightly friable, but were patent after the airways were suctioned.  O2 saturations remained in the mid-to-high 90s.  The patient tolerated the procedure well.  Specimens were submitted for microbiologic examination.  Despite his frail status, he tolerated bronchoscopy quite well.
---
DESCRIPTION: Fiberoptic bronchoscopy for diagnosis of right lung atelectasis and extensive mucus plugging in right main stem bronchus.

surgery, bronchoscopy, fiberoptic, mucomyst, atelectasis, bronchoscope, bronchus, carinae, larynx, main stem, mucus, nasal, plugging, trachea, fiberoptic bronchoscopy, mucus plugging, secretions

The situation involves a medical procedure called bronchoscopy, which is performed to diagnose and address serious respiratory issues such as right lung atelectasis and mucus plugging. While this procedure is generally routine in a controlled medical environment, it is still invasive and carries risks, especially in a possibly frail patient. The potential consequences of the condition not being treated (e.g., respiratory failure) and the inherent risks of anesthesia and the procedure itself contribute to the stakes. Additionally, the presence of a mucocele and a lack of cough reflex further complicate the situation, indicating the potential for aspiration and increased risk. Therefore, the stakes are moderate to high due to the medical context and potential complications.


Medical Specialty: Nephrology
Sample Name: Psychosocial Eval for Kidney Transplant

HISTORY OF PRESENT ILLNESS:,  In 2002, the patient had a blood test during her routine screening, which revealed anemia and an elevated creatinine.  Two weeks later she saw a nephrologist at ABCDE were she worked at that time.  An ultrasound revealed that she had Parenchymal disease in which tissue around the kidney is diseased.  No particular treatment was advised.  She was laid off 6 months later.  In 2004, she began working at The ABCD Hospital and began seeing Dr. A.  She was put on Procrit, but could not keep the stringent appointment scheduled for the injection because of her work.  She began seeing Dr. B and was put on Procrit and Renagel.  She was advised to go on dialysis, but she felt she did not have enough information to such a drastic step.  She saw an endocrinologist for some thyroid problem and her blood work showed that her creatinine was now at 7.  She was referred to Dr. Xyz who found after a parathyroid scan that she may have an adenoma.  Her creatinine is now 7.4.,TREATMENT AND IMPACT OF DISEASE:,  She is on several medications.  She is not on a renal diet yet.  Her energy is good and she is still working full time.,TRANSPLANT FIRST MENTIONED AS TREATMENT OPTION: , She has wanted to transplant ever since dialysis was first mentioned.,EMOTIONAL REACTION TO DIAGNOSIS AND TREATMENT COURSE:,  She is frustrated by the lack of information about what exactly has caused her renal failure and has had a real feeling of helplessness in her efforts to pursue this understanding.,OTHER SIGNIFICANT MEDICAL HISTORY/SURGERIES:,  She had a Bartholin cyst removed in 2002.,PSYCHIATRIC HISTORY:,  None.,COPING STRATEGIES:,  She used to exercise vigorously, but has stopped at this time.  She enjoys watching movies with her children.,COMPLIANCE:,  She feels she watches her diet and medication regimen very closely.  She said she communicates daily with Dr. Xyz,PAST AND PRESENT SMOKING:,  She began smoking 2 cigarettes a day when she was 22, but stopped after a year.,PAST AND PRESENT ALCOHOL USE:,  None.,PAST AND PRESENT DRUG USE:,  None.,LEGAL ISSUES:,  None.,TATTOOS:,  None.,MARITAL STATUS:  LENGTH OF THE TIME MARRIED:,  She has been married for 25 years.,AGE AND HEALTH OF SPOUSE:,  Xyz is 62 and in good health.,CHILDREN:,  Four, all are in good health.,FATHER:,  Father died in 2001, at the age of 62 of cardiac cancer.,MOTHER:,  Dolorous Massey is 63 and in good health.,SIBLINGS:,  Ben Doherty died in 1984 at the age of 26 in an automobile accident; Steven Doherty is 46 and is in good health.,PREVIOUS MARRIAGES AND DURATION OF EACH:,  None.,PERSONS LIVING IN HOUSEHOLD:,  Six.,RELATIONSHIP WITH FAMILY MEMBERS/IDENTIFIED PRIMARY SUPPORT SYSTEM:,  She is close to her brother.,HIGHEST LEVEL OF EDUCATION:,  She has 2 years of college at ABCD College.  She is a licensed LVN.,MILITARY SERVICE:,  None.
---
DESCRIPTION: Psychosocial Evaluation of patient before kidney transplant.

The situation involves a patient with advanced kidney disease considering a transplant, which is a major medical procedure. This evaluation assesses psychosocial readiness for the transplant, including emotional, compliance, and support systems, crucial for the success of the intervention. The patient's creatinine levels indicate significant kidney dysfunction, and the decision to undergo transplant surgery can significantly impact her life expectancy and quality of life. This makes the stakes high in terms of both health outcomes and personal impact.