Medical Specialty: Gastroenterology
Sample Name: Foul-Smelling Urine

CHIEF COMPLAINT:,  Foul-smelling urine and stomach pain after meals.,HISTORY OF PRESENT ILLNESS:,  Stomach pain with most meals x one and a half years and urinary symptoms for same amount of time.  She was prescribed Reglan, Prilosec, Pepcid, and Carafate at ED for her GI symptoms and Bactrim for UTI.  This visit was in July 2010.,REVIEW OF SYSTEMS:,  HEENT:  No headaches.  No visual disturbances, no eye irritation.  No nose drainage or allergic symptoms.  No sore throat or masses.  Respiratory:  No shortness of breath.  No cough or wheeze.  No pain.  Cardiac:  No palpitations or pain.  Gastrointestinal:  Pain and cramping.  Denies nausea, vomiting, or diarrhea.  Has some regurgitation with gas after meals.  Genitourinary:  "Smelly" urine.  Musculoskeletal:  No swelling, pain, or numbness.,MEDICATION ALLERGIES:,  No known drug allergies.,PHYSICAL EXAMINATION:,General:  Unremarkable.,HEENT:  PERRLA.  Gaze conjugate.,Neck:  No nodes.  No thyromegaly.  No masses.,Lungs:  Clear.,Heart:  Regular rate without murmur.,Abdomen:  Soft, without organomegaly, without guarding or tenderness.,Back:  Straight.  No paraspinal spasm.,Extremities:  Full range of motion.  No edema.,Neurologic:  Cranial nerves II-XII intact.  Deep tendon reflexes 2+ bilaterally.,Skin:  Unremarkable.,LABORATORY STUDIES:,  Urinalysis was done, which showed blood due to her period and moderate leukocytes.,ASSESSMENT:,1.  UTI.,2.  GERD.,3.  Dysphagia.,4.  Contraception consult.,PLAN:,1.  Cipro 500 mg b.i.d. x five days.  Ordered BMP, CBC, and urinalysis with microscopy.,2.  Omeprazole 20 mg daily and famotidine 20 mg b.i.d.,3.  Prescriptions same as #2.  Also referred her for a barium swallow series to rule out a stricture.,4.  Ortho Tri-Cyclen Lo.,
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DESCRIPTION: Foul-smelling urine and stomach pain after meals.

The situation involves a patient with chronic gastrointestinal and urinary symptoms, including foul-smelling urine and stomach pain after meals. While the condition has persisted for over a year and requires medical attention, the patient has been evaluated multiple times, prescribed medications, and no immediate life-threatening emergencies are evident in the current assessment. Thus, it involves significant health concerns but is not categorized as high-stakes in terms of urgent or critical intervention needed.


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

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

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

The situation involves a patient with a gastrointestinal bleed being discharged from the hospital. While the source of the bleed is undetermined, it is possibly due to internal hemorrhoids, and the patient's vital signs are stable. The patient is being closely monitored as an outpatient, and certain medications have been adjusted or discontinued. Though the situation requires careful management, the immediate risk appears low since the patient is stable and being discharged. Therefore, while the gastrointestinal bleed itself is a serious condition, the present situation, considering the stability and outpatient follow-up, does not constitute a high-stakes scenario.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Gastroenterology
Sample Name: Exploratory Laparotomy & Colon Resection

PREOPERATIVE DIAGNOSIS: , Colovesical fistula.,POSTOPERATIVE DIAGNOSES:,1.  Colovesical fistula.,2.  Intraperitoneal abscess.,PROCEDURE PERFORMED:,1.  Exploratory laparotomy.,2.  Low anterior colon resection.,3.  Flexible colonoscopy.,4.  Transverse loop colostomy and JP placement.,ANESTHESIA: , General.,HISTORY:  ,This 74-year-old female who had a recent hip fracture and the patient was in rehab when she started having some stool coming out of the urethra.  The patient had retrograde cystogram, which revealed colovesical fistula.  Recommendation for a surgery was made.  The patient was explained the risks and benefits as well as the two sons and the daughter.  They understood that the patient can even die from this procedure.  All the three procedures were explained, without a colostomy, with Hartmann's colostomy, and with a transverse loop colostomy, and out of the three procedures, the patient's requested to have the loop colostomy and stated that the Hartmann's colostomy leaving the anastomosis with the risk of leaking.,PROCEDURE DETAILS: , The patient was taken to the operating room, prepped and draped in the sterile fashion and was given general anesthetic.  An incision was performed in the midline below the umbilicus to the pubis with a #10 blade Bard Parker.  Electrocautery was used for hemostasis down to the fascia.  The fascia was grasped with Ochsner's and then immediately the peritoneum was entered and the incision was carried cephalad and caudad with electrocautery.,Once within the peritoneum, adhesiolysis was performed to separate the small bowel from the attachment of the anterior abdominal wall.  At this point, immediately a small bowel was retracted cephalad.  The patient was taken to a slightly Trendelenburg position and the descending colon was seen.  The white line of Toldt was opened all the way down to the area of inflammation.  At this point, meticulous dissection was carried to separate the small bowel from the attachment to the abscess.  When the small bowel was completely freed of  abscess, bulk of the bladder was seen anteriorly to the uterus.  The abscess was cultured and sent it back to Bacteriology Department and immediately the opening into the bladder was visualized.  At this point, the entire sigmoid colon was separated posteriorly as well as laterally and it was all the way down to sigmoid down to the rectum.  At this point, decision to place a moist towel and retract old intestine superiorly as well as to place first self-retaining retractor in the abdominal cavity with a bladder blade was placed.  Immediately, a GIA was fired right across the descending colon and sigmoid colon junction and then with peons within the mesentery were placed all the way down to the rectosigmoid junction where a TA-55 balloon Roticulator was fired.  The specimen was cut with #10 blade Bard-Parker and sent it to Pathology.  Immediately copious amount of irrigation was used and the staple line in the descending colon was brought with Allis.  A pursestring device was fired.  The staple line was cut.  The dilators were used using #25 and #29, then _________ #29 EEA was placed and the suture was tied.  At this point, attention was directed down to the rectal stump where dilators #25 and #29 were passed from the anus into the rectum and then the #29 Ethicon GIA was introduced.  The spike came posteriorly through the staple line to avoid the inflammatory process anteriorly that was present in the area of the cul-de-sac as well as the uterine was present in this patient.  ,Immediately, the EEA was connected with a mushroom.  It was tied, fired, and a Doyen was placed above the anastomosis approximately four inches.  Fluid was placed within the _________ and immediately a colonoscope was introduced from the patient's anus insufflating air.  No air was seen evolving from the staple line.  All fluid was removed and pictures of the staple line were taken.  The scope was removed at this point.  The case was passed to Dr. X for repair of the vesicle fistula.  Dr. X did repair down the perforation of the bladder that was communicating with an abscess secondary to the perforated diverticulitis and the colon.  After this was performed, copious amount of irrigation was used again.  More lysis of adhesions were performed and decision to make a loop transverse colostomy was made to protect the anastomosis in a phase of a severe inflammatory process in the pelvis in the infected area.  The incision was performed in the right upper quadrant.,This incision was performed with cutting in the cautery, down into the fascia splitting the muscle and then the Penrose was passed under transverse colon, and was grasped on pulling the transverse colon at the level of the skin.  The wire was passed under the transverse colon.  It was left in place.  Moderate irrigation was used in the peritoneal cavity and in the right lower quadrant, a JP was placed in the pelvis posteriorly to the abscess cavity that was down on the pelvis.  At this point, immediately, yellow fluid was removed from the peritoneal cavity and the abdomen was closed with cephalad to caudad and caudad to cephalad with a loop PDS suture and then tied.  Electrocautery for hemostasis and the subcutaneous tissue.  Copious amount of irrigation was used.  The skin was approximated with staples.  At this point, immediately, the wound was covered with a moist towel and decision to mature the loop colostomy was made.  The colostomy was opened longitudinally and then matured with interrupted #3-0 Vicryl suture through the skin edge.  One it was completely matured, immediately the index finger was probed proximally and distally and both loops were completely opened.  As previously mentioned, the Penrose was removed and the Bard was secured with a #3-0 nylon suture.  The JP was secured with #3-0 nylon suture as well.  At this point, dressings were applied.  The patient tolerated the procedure well.  The stent from the left ureter was removed and the Foley was left in place.  The patient did tolerate the procedure well and will be followed up during the hospitalization.
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DESCRIPTION: Exploratory laparotomy, low anterior colon resection, flexible colonoscopy, and transverse loop colostomy and JP placement.  Colovesical fistula and intraperitoneal abscess.

gastroenterology, intraperitoneal abscess, colovesical fistula, low anterior colon resection, flexible colonoscopy, transverse loop colostomy, jp placement, exploratory laparotomy, colon resection, descending colon, transverse colon, colostomy, colon, laparotomy, aparotomy, fistula

This medical situation is high-stakes due to the complexity and severity of the conditions being treated. The patient is undergoing major surgery with significant risks, including the possibility of death, as indicated in the preoperative discussions. The procedure involves multiple complex surgical interventions: exploratory laparotomy, low anterior colon resection, flexible colonoscopy, and creation of a colostomy, all in the context of a colovesical fistula and intraperitoneal abscess. The patient's advanced age and recent medical history, including a hip fracture, add to the complexity and risk. Moreover, the need for precise intraoperative decision-making, coordination among multiple surgical steps, and management of potential complications (such as infection and leakage) further elevate the stakes.


Medical Specialty: Gastroenterology
Sample Name: Esophagoscopy & Foreign Body Removal - 1

PRIMARY DIAGNOSIS:,  Esophageal foreign body, no associated comorbidities are noted.,PROCEDURE:,  Esophagoscopy with removal of foreign body.,CPT CODE: , 43215.,PRINCIPAL DIAGNOSIS:,  Esophageal foreign body, ICD-9 code 935.1.,DESCRIPTION OF PROCEDURE: , Under general anesthesia, flexible EGD was performed.  Esophagus was visualized.  The quarter was visualized at the aortic knob, was removed with grasper.  Estimated blood loss 0.  Intravenous fluids during time of procedure 100 mL.  No tissues.  No complications.  The patient tolerated the procedure well.  Dr. X Pipkin attending pediatric surgeon was present throughout the entire procedure.  The patient was transferred from OR to PACU in stable condition.
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DESCRIPTION: Esophagoscopy with removal of foreign body.   Esophageal foreign body, no associated comorbidities are noted.

gastroenterology, esophagus, foreign body, esophagoscopy, esophageal,

The situation involves a medical procedure for removing a foreign body from the esophagus. Such procedures are routine and carry a low risk of complications when performed by a skilled practitioner, especially in the absence of comorbidities. The procedure was completed without complications, and the patient was stable afterward. However, the ingestion of a foreign body always carries potential risks that need to be addressed promptly, which adds some seriousness to the context. Hence, while it involves a medical intervention, it's a standard procedure with successful completion.


Medical Specialty: Gastroenterology
Sample Name: Esophagogastroduodenoscopy with Biopsies -2

PREOPERATIVE DIAGNOSIS: , Refractory dyspepsia.,POSTOPERATIVE DIAGNOSIS:,1.  Hiatal hernia.,2.  Reflux esophagitis.,PROCEDURE PERFORMED:,  Esophagogastroduodenoscopy with pseudo and esophageal biopsy.,ANESTHESIA:,  Conscious sedation with Demerol and Versed.,SPECIMEN: , Esophageal biopsy.,COMPLICATIONS: , None.,HISTORY:,  The patient is a 52-year-old female morbidly obese black female who has a long history of reflux and GERD type symptoms including complications such as hoarseness and chronic cough.  She has been on multiple medical regimens and continues with dyspeptic symptoms.,PROCEDURE: , After proper informed consent was obtained, the patient was brought to the endoscopy suite.  She was placed in the left lateral position and was given IV Demerol and Versed for sedation.  When adequate level of sedation achieved, the gastroscope was inserted into the hypopharynx and the esophagus was easily intubated.  At the GE junction, a hiatal hernia was present.  There were mild inflammatory changes consistent with reflux esophagitis.  The scope was then passed into the stomach.  It was insufflated and the scope was coursed along the greater curvature to the antrum.  The pylorus was patent.  There was evidence of bile reflux in the antrum.  The duodenal bulb and sweep were examined and were without evidence of mass, ulceration, or inflammation.  The scope was then brought back into the antrum.,A retroflexion was attempted multiple times, however, the patient was having difficulty holding the air and adequate retroflexion view was not visualized.  The gastroscope was then slowly withdrawn.  There were no other abnormalities noted in the fundus or body.  Once again at the GE junction, esophageal biopsy was taken.  The scope was then completely withdrawn.  The patient tolerated the procedure and was transferred to the recovery room in stable condition.  She will return to the General Medical Floor.  We will continue b.i.d proton-pump inhibitor therapy as well as dietary restrictions.  She should also attempt significant weight loss.
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DESCRIPTION: Esophagogastroduodenoscopy with pseudo and esophageal biopsy.  Hiatal hernia and reflux esophagitis. The patient is a 52-year-old female morbidly obese black female who has a long history of reflux and GERD type symptoms including complications such as hoarseness and chronic cough.

gastroenterology, refractory dyspepsia, hiatal hernia, reflux esophagitis, esophagogastroduodenoscopy, esophageal, pseudo, esophageal biopsy, ge junction, hiatal, hernia, esophagitis, antrum, gerd,

The situation involves a routine medical procedure known as an esophagogastroduodenoscopy (EGD), performed to examine upper digestive tract issues, such as refractory dyspepsia, hiatal hernia, and reflux esophagitis. The patient has a history of GERD and symptoms like hoarseness and chronic cough, which are chronic but not life-threatening in the immediate context. The procedure was completed without complications and the patient returned to stable condition. While medical procedures always carry some risk, this is a common and generally low-risk procedure that does not involve any immediate high-stake emergencies.


Medical Specialty: Gastroenterology
Sample Name: Esophagogastroduodenoscopy with Biopsies - 1

PROCEDURE: , Esophagogastroduodenoscopy with gastric biopsies.,INDICATION:,  Abdominal pain.,FINDINGS:,  Antral erythema; 2 cm polypoid pyloric channel tissue, questionable inflammatory polyp which was biopsied; duodenal erythema and erosion.,MEDICATIONS: , Fentanyl 200 mcg and versed 6 mg.,SCOPE: , GIF-Q180.,PROCEDURE DETAIL: , Following the preprocedure patient assessment the procedure, goals, risks including bleeding, perforation and side effects of medications and alternatives were reviewed.  Questions were answered.  Pause preprocedure was performed.,Following titrated intravenous sedation the flexible video endoscope was introduced into the esophagus and advanced to the second portion of the duodenum without difficulty.  The esophagus appeared to have normal motility and mucosa.  Regular Z line was located at 44 cm from incisors.  No erosion or ulceration.  No esophagitis.,Upon entering the stomach gastric mucosa was examined in detail including retroflexed views of cardia and fundus.  There was pyloric channel and antral erythema, but no visible erosion or ulceration.  There was a 2 cm polypoid pyloric channel tissue which was suspicious for inflammatory polyp.  This was biopsied and was placed separately in bottle #2.  Random gastric biopsies from antrum, incisura and body were obtained and placed in separate jar, bottle #1.  No active ulceration was found.,Upon entering the duodenal bulb there was extensive erythema and mild erosions, less than 3 mm in length, in first portion of duodenum, duodenal bulb and junction of first and second part of the duodenum.  Postbulbar duodenum looked normal.,The patient was assessed upon completion of the procedure.  Okay to discharge once criteria met.,Follow up with primary care physician.,I met with patient afterward and discussed with him avoiding any nonsteroidal anti-inflammatory medication.  Await biopsy results.
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DESCRIPTION: Esophagogastroduodenoscopy with gastric biopsies.  Antral erythema; 2 cm polypoid pyloric channel tissue, questionable inflammatory polyp which was biopsied; duodenal erythema and erosion.

gastroenterology, gastric biopsies, duodenal erythema, inflammatory polyp, pyloric channel tissue, pyloric channel, esophagogastroduodenoscopy, pyloric, duodenal, duodenum, polypoid,

The procedure described is a routine esophagogastroduodenoscopy, which is a common diagnostic procedure in gastroenterology. While it involves some risks, such as bleeding or perforation, these are generally well-managed. The potential findings from the procedure could influence patient management, which adds some importance, especially concerning the identification of inflammatory polyps. However, this type of procedure is not unusual, and the stakes are not excessively high unless there is a critical or life-threatening finding, which the sample description doesn't suggest.


Medical Specialty: Gastroenterology
Sample Name: Esophagogastroduodenoscopy - 7

PREOPERATIVE DIAGNOSIS:,  Positive peptic ulcer disease.,POSTOPERATIVE DIAGNOSIS:,  Gastritis.,PROCEDURE PERFORMED: , Esophagogastroduodenoscopy with photography and biopsy.,GROSS FINDINGS:,  The patient had a history of peptic ulcer disease, epigastric abdominal pain x2 months, being evaluated at this time for ulcer disease.,Upon endoscopy, gastroesophageal junction was at 40 cm, no esophageal tumor, varices, strictures, masses, or no reflux esophagitis was noted.  Examination of the stomach reveals mild inflammation of the antrum of the stomach, no ulcers, erosions, tumors, or masses.  The profundus and the cardia of the stomach were unremarkable.  The pylorus was concentric.  The duodenal bulb and sweep with no inflammation, tumors, or masses.,OPERATIVE PROCEDURE: , The patient taken to the Endoscopy Suite, prepped and draped in the left lateral decubitus position.  She was given IV sedation using Demerol and Versed.  Olympus videoscope was inserted in the hypopharynx, upon deglutition passed into the esophagus.  Using air insufflation, the scope was advanced down through the esophagus into the stomach along the greater curvature of the stomach to the pylorus to the duodenal bulb and sweep.  The above gross findings noted.  The panendoscope was withdrawn back from the stomach, deflected upon itself.  The lesser curve fundus and cardiac were well visualized.  Upon examination of these areas, panendoscope was returned to midline.  Photographs and biopsies were obtained of the antrum of the stomach.  Air was aspirated from the stomach and panendoscope was slowly withdrawn carefully examining the lumen of the bowel.,Photographs and biopsies were obtained as appropriate.  The patient is sent to recovery room in stable condition.
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DESCRIPTION: Positive peptic ulcer disease.  Gastritis.  Esophagogastroduodenoscopy with photography and biopsy.   The patient had a history of peptic ulcer disease, epigastric abdominal pain x2 months, being evaluated at this time for ulcer disease.

gastroenterology, antrum, esophageal tumor, varices, strictures, masses, duodenal bulb, peptic ulcer, duodenal, esophagus, esophagogastroduodenoscopy, panendoscope, peptic, inflammation, ulcer, disease, stomach

The procedure described is a diagnostic esophagogastroduodenoscopy, which is a routine and commonly performed procedure. The findings of gastritis and history of peptic ulcer disease are relatively standard diagnoses in gastroenterology. The procedure appears to have been conducted without complications, as the patient was sent to recovery in stable condition. Therefore, this situation is not high-stakes, as it involves standard medical practice without immediate life-threatening conditions or complications.


Medical Specialty: Gastroenterology
Sample Name: Esophagogastroduodenoscopy - 6

PROCEDURE IN DETAIL: , Following premedication with Vistaril 50 mg and Atropine 0.4 mg IM, the patient received Versed 5.0 mg intravenously after Cetacaine spray to the posterior palate.  The Olympus video gastroscope was then introduced into the upper esophagus and passed by direct vision to the descending duodenum.  The upper, mid and lower portions of the esophagus; the lesser and greater curves of the stomach; anterior and posterior walls; body and antrum; pylorus; duodenal bulb; and duodenum were all normal.  No evidence of friability, ulceration or tumor mass was encountered.  The instrument was withdrawn to the antrum, and biopsies taken for CLO testing, and then the instrument removed.
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DESCRIPTION: Esophagogastroduodenoscopy.   The Olympus video gastroscope was then introduced into the upper esophagus and passed by direct vision to the descending duodenum.

gastroenterology, cetacaine, pylorus, antrum, duodenum, upper esophagus, esophagogastroduodenoscopy, descending, esophagusNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

The procedure described, an esophagogastroduodenoscopy (EGD), is a commonly performed diagnostic test to evaluate the upper digestive system. While it's generally routine, it involves anesthesia and carries potential risks inherent to any invasive procedure, such as bleeding, infection, or adverse reactions to sedation. However, these risks are normally well-managed in clinical practice. The results, indicating no abnormalities or masses, further suggest that the procedure was standard and without complications in this case.


Medical Specialty: Gastroenterology
Sample Name: ERCP

PROCEDURE:, Endoscopic retrograde cholangiopancreatography with brush cytology and biopsy.,INDICATION FOR THE PROCEDURE:, Patient with a history of chronic abdominal pain and CT showing evidence of chronic pancreatitis, with a recent upper endoscopy showing an abnormal-appearing ampulla.,MEDICATIONS:, General anesthesia.,The risks of the procedure were made aware to the patient and consisted of medication reaction, bleeding, perforation, aspiration, and post ERCP pancreatitis.,DESCRIPTION OF PROCEDURE: ,After informed consent and appropriate sedation, the duodenoscope was inserted into the oropharynx, down the esophagus, and into the stomach. The scope was then advanced through the pylorus to the ampulla. The ampulla had a markedly abnormal appearance, as it was enlarged and very prominent. It extended outward with an almost polypoid shape. It had what appeared to be adenomatous-appearing mucosa on the tip. There also was ulceration noted on the tip of this ampulla. The biliary and pancreatic orifices were identified. This was located not at the tip of the ampulla, but rather more towards the base. Cannulation was performed with a Wilson-Cooke TriTome sphincterotome with easy cannulation of the biliary tree. The common bile duct was mildly dilated, measuring approximately 12 mm. The intrahepatic ducts were minimally dilated. There were no filling defects identified. There was felt to be a possible stricture within the distal common bile duct, but this likely represented an anatomic variant given the abnormal shape of the ampulla. The patient has no evidence of obstruction based on lab work and clinically. Nevertheless, it was decided to proceed with brush cytology of this segment. This was done without any complications. There was adequate drainage of the biliary tree noted throughout the procedure. Multiple efforts were made to access the pancreatic ductal anatomy; however, because of the shape of the ampulla, this was unsuccessful. Efforts were made to proceed in a long scope position, but still were unsuccessful. Next, biopsies were obtained of the ampulla away from the biliary orifice. Four biopsies were taken. There was some minor oozing which had ceased by the end of the procedure. The stomach was then decompressed and the endoscope was withdrawn.,FINDINGS:,1. Abnormal papilla with bulging, polypoid appearance, and looks adenomatous with ulceration on the tip; biopsies taken.,2. Cholangiogram reveals mildly dilated common bile duct measuring 12 mm and possible distal CBD stricture, although I think this is likely an anatomic variant; brush cytology obtained.,3. Unable to access the pancreatic duct.,RECOMMENDATIONS:,1. NPO except ice chips today.,2. Will proceed with MRCP to better delineate pancreatic ductal anatomy.,3. Follow up biopsies and cytology.
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DESCRIPTION: Endoscopic retrograde cholangiopancreatography (ERCP) with brush cytology and biopsy.

gastroenterology, endoscopic retrograde cholangiopancreatography, biopsy, brush cytology, cholangiopancreatography, pancreatitis, endoscopy, duodenoscope, wilson-cooke tritome, ampulla, common bile duct, ercp, endoscopic, biliary, pancreatic, duct, biopsies, cytology

The situation involves a medical procedure known as ERCP, which is generally considered a high-stakes procedure due to its invasive nature and the potential risks involved. The risks noted include serious complications such as bleeding, perforation, and post-ERCP pancreatitis. Moreover, the procedure was performed under general anesthesia, further indicating its complexity and seriousness. The findings of an abnormal ampulla and attempts to diagnose potential strictures also highlight the importance of this procedure in diagnosing serious medical conditions. Given these factors, the stakes are relatively high.


Medical Specialty: Gastroenterology
Sample Name: Endovascular Abdominal Aortic Aneurysm Repair

PREOPERATIVE DIAGNOSIS: , Abdominal aortic aneurysm.,POSTOPERATIVE DIAGNOSIS: , Abdominal aortic aneurysm.,OPERATION PERFORMED:,  Endovascular abdominal aortic aneurysm repair.,FINDINGS: , The patient was brought to the OR with the known 4 cm abdominal aortic aneurysm + 2.5 cm right common iliac artery aneurysm.  A Gore exclusive device was used 3 pieces were used to effect the repair.  We had to place an iliac extender down in to right external iliac artery to manage the right common iliac artery aneurysm.  The right hypogastric artery had been previously coiled off.  Left common femoral artery was used for the _____ side.  We had small type 2 leak right underneath the take off the renal arteries, this was not felt to be type I leak and this was very delayed filling and it was felt that this was highly indicative of type 2 leak from a lumbar artery, which commonly come off in this area.  It was felt that this would seal after reversal of the anticoagulation given sufficient time.,PROCEDURE: , With the patient supine position under general anesthesia, the abdomen and lower extremities were prepped and draped in a sterile fashion.,Bilateral groin incisions were made, and the common femoral arteries were dissected out bilaterally.  The patient was then heparinized.,The 7-French sheaths were then placed retrograde bilaterally.,A stiff Amplatz wires were then placed up the right femoral artery and a stiff Amplatz were placed left side a calibrated catheter was placed up the right side.  The calibrated aortogram was the done.  We marked the renal arteries aortic bifurcation and bifurcation, common iliac arteries.  We then preceded placement of the main trunk, by replacing the 7 French sheath in the left groin area with 18-french sheath and then deployed the trunk body just below the take off renal arteries.,Once the main trunk has been deployed within wired _____ then deployed an iliac limb down in to the right common iliac artery.  As noted above, we then had to place an iliac extension, down in the external iliac artery to exclude the right common iliac artery and resume completely.,Following completion of the above all arteries were ballooned appropriately.  A completion angiogram was done which showed late small type 2 leak just under the take off renal arteries.  The area was ballooned aggressively.  It was felt that this would dissolve as discussed above.,Following completion of the above all wire sheaths etc., were removed from both groin areas.  Both femoral arteries were repaired by primary suture technique.  Flow was then reestablished to the lower extremities, and protamine was given to reverse the heparin.,Both surgical sites were then irrigated thoroughly.  Meticulous hemostasis was achieved.  Both wounds were then closed in a routine layered fashion.,Sterile antibiotic dressings were applied.  Sponge and needle counts were reported as correct.  The patient tolerated the procedure well the patient was taken to the recovery room in satisfactory condition.
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DESCRIPTION: The patient was brought to the OR with the known 4 cm abdominal aortic aneurysm + 2.5 cm right common iliac artery aneurysm.

gastroenterology, gore, common iliac artery aneurysm, abdominal aortic aneurysm repair, abdominal aortic aneurysm, common iliac, aortic aneurysm, iliac artery, artery, aneurysm, iliac, abdominal, aortic, arteries,

The situation involves an endovascular abdominal aortic aneurysm repair, a surgical procedure to address significant vascular issues. The presence of an abdominal aortic aneurysm, with potential complications such as a rupture, presents serious health risks, including life-threatening bleeding. Although the procedure was routine and the patient tolerated it well, the nature of the condition and the critical care required make it a high-stakes situation.


Medical Specialty: Gastroenterology
Sample Name: Esophagogastroduodenoscopy - 10

PREOPERATIVE DIAGNOSIS: , Nausea and vomiting and upper abdominal pain.,POST PROCEDURE DIAGNOSIS:  ,Normal upper endoscopy.,OPERATION: , Esophagogastroduodenoscopy with antral biopsies for H. pylori x2 with biopsy forceps.,ANESTHESIA:,  IV sedation 50 mg Demerol, 8 mg of Versed.,PROCEDURE: , The patient was taken to the endoscopy suite.  After adequate IV sedation with the above medications, hurricane was sprayed in the mouth as well as in the esophagus.  A bite block was placed and the gastroscope placed into the mouth and was passed into the esophagus and negotiated through the esophagus, stomach, and pylorus.  The first, second, and third portions of the duodenum were normal.  The scope was withdrawn into the antrum which was normal and two bites with the biopsy forceps were taken in separate spots for H. pylori.  The scope was retroflexed which showed a normal GE junction from the inside of the stomach and no evidence of pathology or paraesophageal hernia.  The scope was withdrawn at the GE junction which was in a normal position with a normal transition zone.  The scope was then removed throughout the esophagus which was normal.  The patient tolerated the procedure well.,The plan is to obtain a HIDA scan as the right upper quadrant ultrasound appeared to be normal, although previous ultrasounds several years ago showed a gallstone.
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DESCRIPTION: Esophagogastroduodenoscopy with antral biopsies for H. pylori x2 with biopsy forceps.  Nausea and vomiting and upper abdominal pain.

gastroenterology, h. pylori, forceps, antral biopsies, ge junction, esophagogastroduodenoscopy, pylori, esophagus, antral,

The procedure described is an esophagogastroduodenoscopy (EGD), which is a common, minimally invasive diagnostic procedure to visually inspect the upper digestive system. Although it involves sedation and some risk, it is generally routine and not high-stakes, especially since the patient tolerated the procedure well and no immediate complications were noted. The findings were normal, which suggests low urgency in this scenario. The planned follow-up with a HIDA scan for further exploration also indicates routine follow-up care rather than an emergency or high-stakes situation.


Medical Specialty: Gastroenterology
Sample Name: Endoscopy - 4

PROCEDURE: , Endoscopy.,CLINICAL INDICATIONS: , Intermittent rectal bleeding with abdominal pain.,ANESTHESIA: , Fentanyl 100 mcg and 5 mg of IV Versed.,PROCEDURE:,  The patient was taken to the GI lab and placed in the left lateral supine position.  Continuous pulse oximetry and blood pressure monitoring were in place.  After informed consent was obtained, the video endoscope was inserted over the dorsum of the tongue without difficulty.  With swallowing, the scope was advanced down the esophagus into the body of the stomach.  The scope was further advanced down to the antrum and through the pylorus into the duodenum, which was visualized into its second portion.  It appeared free of stricture, neoplasm, or ulceration.  Samples were obtained from the antrum and prepyloric area to check for Helicobacter, rapid urease, and additional samples were sent to pathology.  Retroflexion view of the fundus of the stomach was normal without evidence of a hiatal hernia.  The scope was then slowly removed.  The distal esophagus appeared benign with a normal-appearing gastroesophageal sphincter and no esophagitis.  The remaining portion of the esophagus was normal.,IMPRESSION:,  Abdominal pain.  Symptoms most consistent with gastroesophageal reflux disease without endoscopic evidence of hiatal hernia.,RECOMMENDATIONS:,  Await results of CLO testing and biopsies.  Return to clinic with Dr. Spencer in 2 weeks for further discussion.
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DESCRIPTION: Intermittent rectal bleeding with abdominal pain.

gastroenterology, duodenum, stomach, hiatal hernia, endoscopy, antrum, hiatal, hernia, gastroesophageal, scope, esophagus, abdominal

The procedure described is a standard endoscopy to diagnose potential causes of gastrointestinal symptoms, such as gastroesophageal reflux disease or ulcers. While important for diagnostic purposes, the procedure itself is routine in the field of gastroenterology and not inherently high-stakes unless complications arise or severe pathologies are discovered. The endoscopy findings were mostly normal, with recommendations to await test results and follow-up, indicating stable patient management and no immediate critical condition.


Medical Specialty: Gastroenterology
Sample Name: Endoscopy - 3

PROCEDURES PERFORMED: , Endoscopy.,INDICATIONS: , Dysphagia.,POSTOPERATIVE DIAGNOSIS:,  Esophageal ring and active reflux esophagitis.,PROCEDURE: , Informed consent was obtained prior to the procedure from the parents and patient.  The oral cavity is sprayed with lidocaine spray.  A bite block is placed.  Versed IV 5 mg and 100 mcg of IV fentanyl was given in cautious increments.  The GIF-160 diagnostic gastroscope used.  The patient was alert during the procedure.  The esophagus was intubated under direct visualization.  The scope was advanced toward the GE junction with active reflux esophagitis involving the distal one-third of the esophagus noted.  The stomach was unremarkable.  Retroflexed exam unremarkable.  Duodenum not intubated in order to minimize the time spent during the procedure.  The patient was alert although not combative.  A balloon was then inserted across the GE junction, 15 mm to 18 mm, and inflated to 3, 4.7, and 7 ATM, and left inflated at 18 mm for 45 seconds.  The balloon was then deflated.  The patient became uncomfortable and a good-size adequate distal esophageal tear was noted.  The scope and balloon were then withdrawn.  The patient left in good condition.,IMPRESSION: , Successful dilation of distal esophageal fracture in the setting of active reflux esophagitis albeit mild.,PLAN: , I will recommend that the patient be on lifelong proton pump inhibition and have repeat endoscopy performed as needed.  This has been discussed with the parents.  He was sent home with a prescription for omeprazole.
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DESCRIPTION: Patient with dysphagia.

Patient with dysphagia.

gastroenterology, active reflux esophagitis, ge junction, distal esophageal, active reflux, reflux esophagitis, dysphagia, esophagus, scope, ge, junction, endoscopy, esophageal, reflux, esophagitis, distal, balloon

The situation involves a medical procedure, specifically an endoscopy with dilation of the esophagus for a patient with dysphagia and reflux esophagitis. This is a moderately high-stakes situation since it involves patient sedation, a potential risk of esophageal tear during the dilation, and decisions regarding lifelong medication. However, the report does not suggest any immediate life-threatening complications, and the patient was discharged in good condition. The stakes are significant but not extremely high as the procedure was successful and the patient is on a management plan.


Medical Specialty: Gastroenterology
Sample Name: EGD Template - 2

The patient was placed in the left lateral decubitus position, medicated with the above medications to achieve and maintain a conscious sedation.  Vital signs were monitored throughout the procedure without evidence of hemodynamic compromise or desaturation.,The Olympus single-channel endoscope was passed under direct visualization through the oral cavity and advanced to the second portion of the duodenum.,FINDINGS:,ESOPHAGUS:  Proximal and mid esophagus were without abnormalities.,STOMACH:  Insufflated and retroflexed visualization of the gastric cavity revealed,DUODENUM:  Normal.
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DESCRIPTION: Common description of EGD.

Common description of EGD.

gastroenterology, gastric cavity, lateral decubitus position, endoscope, olympus, egd, visualization, cavity, duodenum, esophagusNOTE

The scenario describes a routine procedure in gastroenterology, specifically an Esophagogastroduodenoscopy (EGD). The procedure's findings indicate no abnormalities, suggesting it was uneventful and typical. The mention of conscious sedation and vital sign monitoring is standard practice to ensure safety, but the overall context does not elevate the situation to a high-stakes scenario.


Medical Specialty: Gastroenterology
Sample Name: Diverticulectomy & Laparotomy

PREOPERATIVE DIAGNOSIS: , Acute appendicitis.,POSTOPERATIVE DIAGNOSIS: , Perforated Meckel's diverticulum.,PROCEDURES PERFORMED:,1.  Diagnostic laparotomy.,2.  Exploratory laparotomy.,3.  Meckel's diverticulectomy.,4.  Open incidental appendectomy.,5.  Peritoneal toilet.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS:  ,300 ml.,URINE OUTPUT: , 200 ml.,TOTAL FLUID:,  1600 mL.,DRAIN:,  JP x1 right lower quadrant and anterior to the rectum.,TUBES:,  Include an NG and a Foley catheter.,SPECIMENS: , Include Meckel's diverticulum and appendix.,COMPLICATIONS: , Ventilator-dependent respiratory failure with hypoxemia following closure.,BRIEF HISTORY: , This is a 45-year-old Caucasian gentleman presented to ABCD General Hospital with acute onset of right lower quadrant pain that began 24 hours prior to this evaluation.,The pain was very vague and progressed in intensity.  The patient has had anorexia with decrease in appetite.  His physical examination revealed the patient to be febrile with the temperature of 102.4.  He had right lower quadrant and suprapubic tenderness with palpation with Rovsing sign and rebound consistent with acute surgical abdomen.  The patient was presumed acute appendicitis and was placed on IV antibiotics and recommended that he undergo diagnostic laparoscopy with possible open exploratory laparotomy.  He was explained the risks, benefits, and complications of the procedure and gave informed consent to proceed.,OPERATIVE FINDINGS: , Diagnostic laparoscopy revealed purulent drainage within the region of the right lower quadrant adjacent to the cecum and terminal ileum.  There was large amounts of purulent drainage.  The appendix was visualized, however, it was difficult to be visualized secondary to the acute inflammatory process, purulent drainage, and edema.  It was decided given the signs of perforation and purulent drainage within the abdomen that we would convert to an open exploratory laparotomy.  Upon exploration of the ileum, there was noted to be a ruptured Meckel's diverticulum, this was resected.  Additionally, the appendix appeared normal without evidence of perforation and/or edema and a decision to proceed with incidental appendectomy was performed.  The patient was irrigated with copious amounts of warmth normal saline approximately 2 to 3 liters.  The patient was closed and did develop some hypoxemia after closure.  He remained ventilated and was placed on a large amount of ________.  His hypoxia did resolve and he remained intubated and proceed to the Critical Care Complex or postop surgical care.,OPERATIVE PROCEDURE:,  The patient was brought to the operative suite and placed in the supine position.  He did receive preoperative IV antibiotics, sequential compression devices, NG tube placement with Foley catheter, and heparin subcutaneously.  The patient was intubated by the Anesthesia Department.  After adequate anesthesia was obtained, the abdomen was prepped and draped in the normal sterile fashion with Betadine solution.  Utilizing a #10 blade scalpel, an infraumbilical incision was created.  The Veress needle was inserted into the abdomen.  The abdomen was insufflated to approximately 15 mmHg.  A #10 mm ablated trocar was inserted into the abdomen and a video laparoscope was inserted and the abdomen was explored and the above findings were noted.  A right upper quadrant 5 mm port was inserted to help with manipulation of bowel and to visualize the appendix.  Decision was then made to convert to exploratory laparotomy given the signs of acute perforation.  The instruments were then removed.  The abdomen was then deflated.  Utilizing ________ #10 blade scalpel, a midline incision was created from the xiphoid down to level of the pubic symphysis.,The incision was carried down with a #10 blade scalpel and the bleeding was controlled along the way with electrocautery.  The posterior layer of the rectus fascia and peritoneum was opened carefully with the scissors as the peritoneum had already been penetrated during laparoscopy.  Incision was carried down to the midline within the linea alba.  Once the abdomen was opened, there was noted to be gross purulent drainage.  The ileum was explored and there was noted to be a perforated Meckel's diverticulum.  Decision to resect the diverticulum was performed.,The blood supply to the Meckel's diverticulum was carefully dissected free and a #3-0 Vicryl was used to tie off the blood supply to the Meckel's diverticulum.  Clamps were placed to the proximal supply to the Meckel's diverticulum was tied off with #3-0 Vicryl sutures.  The Meckel's diverticulum was noted to be completely free and was grasped anteriorly and utilizing a GIA stapling device, the diverticulum was transected.  There was noted to be a hemostatic region within the transection and staple line looked intact without evidence of perforation and/or leakage.  Next, decision was decided to go ahead and perform an appendectomy.  Mesoappendix was doubly clamped with hemostats and cut with Metzenbaum scissors.  The appendiceal artery was identified and was clamped between two hemostats and transected as well.  Once the appendix was completely freed of the surrounding inflammation and adhesion.  A plain gut was placed at the base of the appendix and tied down.  The appendix was milked distally with a straight stat and clamped approximately halfway.  A second piece of plain gut suture was used to ligate above and then was transected with a #10 blade scalpel.  The appendiceal stump was then inverted with a pursestring suture of #2-0 Vicryl suture.  Once the ________ was completed, decision to place a JP drain within the right lower quadrant was performed.  The drain was positioned within the right lower quadrant and anterior to the rectum and brought out through a separate site in the anterior abdominal wall.  It was sewn in place with a #3-0 nylon suture.  The abdomen was then irrigated with copious amounts of warmed normal saline.  The remainder of the abdomen was unremarkable for pathology.  The omentum was replaced over the bowel contents and utilizing #1-0 PDS suture, the abdominal wall, anterior and posterior rectus fascias were closed with a running suture.  Once the abdomen was completely closed, the subcutaneous tissue was irrigated with copious amounts of saline and the incision was closed with staples.  The previous laparoscopic sites were also closed with staples.  Sterile dressings were placed over the wound with Adaptic and 4x4s and covered with ABDs.  JPs replaced with bulb suction.  NG tube and Foley catheter were left in place.  The patient tolerated this procedure well with exception of hypoxemia which resolved by the conclusion of the case.,The patient will proceed to the Critical Care Complex where he will be closely evaluated and followed in his postoperative course.  To remain on IV antibiotics and we will manage ventilatory-dependency of the patient.
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DESCRIPTION: Diagnostic laparotomy, exploratory laparotomy, Meckel's diverticulectomy, open incidental appendectomy, and peritoneal toilet.

The situation involves a patient undergoing multiple significant surgical procedures, including a Meckel's diverticulectomy and an appendectomy, due to a perforated diverticulum. The postoperative complications include ventilator-dependent respiratory failure with hypoxemia, indicating a serious risk to the patient's health and recovery. The need for intensive monitoring in the Critical Care Complex further highlights the critical nature of the situation.


Medical Specialty: Gastroenterology
Sample Name: EGD - Colonoscopy - Polypectomy

PROCEDURES:,1.  Esophagogastroduodenoscopy.,2.  Colonoscopy with polypectomy.,PREOPERATIVE DIAGNOSES:,1.  History of esophageal cancer.,2.  History of colonic polyps.,POSTOPERATIVE FINDINGS:,1.  Intact surgical intervention for a history of esophageal cancer.,2.  Melanosis coli.,3.  Transverse colon polyps in the setting of surgical changes related to partial and transverse colectomy.,MEDICATIONS:,  Fentanyl 250 mcg and 9 mg of Versed.,INDICATIONS:,  The patient is a 55-year-old dentist presenting for surveillance upper endoscopy in the setting of a history of esophageal cancer with staging at T2N0M0.,He also has a history of adenomatous polyps and presents for surveillance of this process.,Informed consent was obtained after explanation of the procedures, as well as risk factors of bleeding, perforation, and adverse medication reaction.,ESOPHAGOGASTRODUODENOSCOPY:,  The patient was placed in the left lateral decubitus position and medicated with the above medications to achieve and maintain a conscious sedation.  Vital signs were monitored throughout the procedure without evidence of hemodynamic compromise or desaturation.  The Olympus single-channel endoscope was passed under direct visualization, through the oral cavity, and advanced to the second portion of the duodenum.,FINDINGS:,1.  ESOPHAGUS:  Anatomy consistent with esophagectomy with colonic transposition.,2.  STOMACH:  Revealed colonic transposition with normal mucosa.,3.  DUODENUM:  Normal.,IMPRESSION: , Intact surgical intervention with esophagectomy colonic transposition.,COLONOSCOPY: , The patient was then turned and a colonic 140-series colonoscope was passed under direct visualization through the anal verge and advanced to the cecum as identified by the appendiceal orifice.  Circumferential visualization the colonic mucosa revealed the following:,1.  Cecum revealed melanosis coli.,2.  Ascending, melanosis coli.,3.  Transverse revealed two diminutive sessile polyps, excised by cold forceps technique and submitted to histology as specimen #1 with surgical changes consistent with partial colectomy related to the colonic transposition.,4.  Descending, melanosis coli.,5.  Sigmoid, melanosis coli.,6.  Rectum, melanosis coli.,IMPRESSION: , Diffuse melanosis coli with incidental finding of transverse colon polyps.,RECOMMENDATION: , Follow-up histology.  Continue fiber with avoidance of stimulant laxatives.
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DESCRIPTION: Esophagogastroduodenoscopy and colonoscopy with polypectomy

The situation involves a detailed description of a dual medical procedure: an esophagogastroduodenoscopy and a colonoscopy with polypectomy on a patient with a history of esophageal cancer and colonic polyps. These procedures are significant due to the patient's medical history, the risks associated with the procedures, such as bleeding and perforation, and the potential findings, which could indicate cancer recurrence or other significant issues. However, this is a routine surveillance and detection scenario in a clinical context where such procedures are expected and consented to, rather than an unexpected emergency situation.


Medical Specialty: Gastroenterology
Sample Name: Discharge Summary - Cholelithiasis

ADMISSION DIAGNOSIS: , Symptomatic cholelithiasis.,DISCHARGE DIAGNOSIS:,  Symptomatic cholelithiasis.,SERVICE: , Surgery.,CONSULTS:,  None.,HISTORY OF PRESENT ILLNESS: , Ms. ABC is a 27-year-old woman who apparently presented with complaint of symptomatic cholelithiasis.  She was afebrile.  She was taken by Dr. X to the operating room.,HOSPITAL COURSE: , The patient underwent a procedure.  She tolerated without difficulty.  She had her pain controlled with p.o. pain medicine.  She was afebrile.  She is tolerating liquid diet.  It was felt that the patient is stable for discharge.  She did complain of bladder spasms when she urinated and she did say that she has a history of chronic UTIs.  We will check a UA and urine culture prior to discharge.  I will give her prescription for ciprofloxacin that she can take for 3 days presumptively and I have discharged her home with omeprazole and Colace to take over-the-counter for constipation and we will send her home with Percocet for pain.  Her labs were within normal limits.  She did have an elevated white blood cell count, but I believe this is just leukemoid reaction, but she is afebrile, and if she does have UTI, may also be related.  Her labs in terms of her bilirubin were within normal limits.  Her LFTs were slightly elevated, I do believe this is related to the cautery used on the liver bed.  They were 51 and 83 for the AST and ALT respectively.  I feel that she looks good for discharge.,DISCHARGE INSTRUCTIONS: , Clear liquid diet x48 hours and she can return to her Medifast, she may shower.  She needs to keep her wound clean and dry.  She is not to engage in any heavy lifting greater than 10 pounds x2 weeks.  No driving for 1 to 2 weeks.  She must be able to stop in an emergency and be off narcotic meds, no strenuous activity, but she needs to maintain mobility.  She can resume her medications per med rec sheets.,DISCHARGE MEDICATIONS: , As previously mentioned.,FOLLOWUP:,  We will follow up on both urinalysis and cultures.  She is instructed to follow up with Dr. X in 2 weeks.  She needs to call for any shortness of breath, temperature greater than 101.5, chest pain, intractable nausea, vomiting, and abdominal pain, any redness, swelling or foul smelling drainage from her wounds.
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DESCRIPTION: Patient with complaint of symptomatic cholelithiasis.

gastroenterology, medifast, liquid diet, symptomatic cholelithiasis, symptomatic, cholelithiasis, discharge,

The situation involves a medical discharge summary for a patient with symptomatic cholelithiasis who has undergone surgery. It includes instructions for post-operative care, medication management, and follow-up. While there are potential complications that could arise if instructions are not followed properly, the patient's condition appears stable, and the document seems routine for recovery from a common procedure. Given the nature of medical care with possible health risks, it is moderate in terms of stakes, but not extremely high-stakes because the surgery was reported as tolerated well and no immediate life-threatening conditions are indicated.


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Medical Specialty: Gastroenterology
Sample Name: CT Abdomen & Pelvis - 8

CT ABDOMEN WITH AND WITHOUT CONTRAST AND CT PELVIS WITH CONTRAST,REASON FOR EXAM: , Generalized abdominal pain, nausea, diarrhea, and recent colonic resection in 11/08.,TECHNIQUE:,  Axial CT images of the abdomen were obtained without contrast.  Axial CT images of the abdomen and pelvis were then obtained utilizing 100 mL of Isovue-300.,FINDINGS: , The liver is normal in size and attenuation.,The gallbladder is normal.,The spleen is normal in size and attenuation.,The adrenal glands and pancreas are unremarkable.,The kidneys are normal in size and attenuation.,No hydronephrosis is detected.  Free fluid is seen within the right upper quadrant within the lower pelvis.  A markedly thickened loop of distal small bowel is seen.  This segment measures at least 10-cm long.  No definite pneumatosis is appreciated.  No free air is apparent at this time.  Inflammatory changes around this loop of bowel.  Mild distention of adjacent small bowel loops measuring up to 3.5 cm is evident.  No complete obstruction is suspected, as there is contrast material within the colon.  Postsurgical changes compatible with the partial colectomy are noted.  Postsurgical changes of the anterior abdominal wall are seen.  Mild thickening of the urinary bladder wall is seen.,IMPRESSION:,1.  Marked thickening of a segment of distal small bowel is seen with free fluid within the abdomen and pelvis.  An inflammatory process such as infection or ischemia must be considered.  Close interval followup is necessary.,2.  Thickening of the urinary bladder wall is nonspecific and may be due to under distention.  However, evaluation for cystitis is advised.
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DESCRIPTION: Generalized abdominal pain, nausea, diarrhea, and recent colonic resection.  CT abdomen with and without contrast and CT pelvis with contrast.  Axial CT images of the abdomen were obtained without contrast.  Axial CT images of the abdomen and pelvis were then obtained utilizing 100 mL of Isovue-300.

gastroenterology, abdominal pain, nausea, diarrhea, colonic resection, axial ct images, ct abdomen, isovue, inflammatory, urinary, bladder, abdominal, colonic, wall, thickening, axial, bowel, contrast, attenuation, pelvis, ct, abdomen

The situation involves a detailed CT scan report for a patient with generalized abdominal pain, nausea, diarrhea, and a recent colonic resection. The findings suggest a significant medical issue, possibly involving an inflammatory process like infection or ischemia. This requires close follow-up and potentially urgent medical intervention to prevent further complications. Such scenarios are typically high-stakes due to the potential for life-threatening complications if not addressed promptly.


Medical Specialty: Gastroenterology
Sample Name: CT Abdomen & Pelvis - 7

REASON FOR EXAM: , Lower quadrant pain with nausea, vomiting, and diarrhea.,TECHNIQUE: , Noncontrast axial CT images of the abdomen and pelvis are obtained.,FINDINGS: , Please note evaluation of the abdominal organs is secondary to the lack of intravenous contrast material.,Gallstones are seen within the gallbladder lumen.  No abnormal pericholecystic fluid is seen.,The liver is normal in size and attenuation.,The spleen is normal in size and attenuation.,A 2.2 x 1.8 cm low attenuation cystic lesion appears to be originating off of the tail of the pancreas.  No pancreatic ductal dilatation is seen.  There is no abnormal adjacent stranding.  No suspected pancreatitis is seen.,The kidneys show no stone formation or hydronephrosis.,The large and small bowels are normal in course and caliber.  There is no evidence for obstruction.  The appendix appears within normal limits.,In the pelvis, the urinary bladder is unremarkable.  There is a 4.2 cm cystic lesion of the right adnexal region.  No free fluid, free air, or lymphadenopathy is detected.,There is left basilar atelectasis.,IMPRESSION:,1.  A 2.2 cm low attenuation lesion is seen at the pancreatic tail.  This is felt to be originating from the pancreas, a cystic pancreatic neoplasm must be considered and close interval followup versus biopsy is advised.  Additionally, when the patient's creatinine improves, a contrast-enhanced study utilizing pancreatic protocol is needed.  Alternatively, an MRI may be obtained.,2.  Cholelithiasis.,3.  Left basilar atelectasis.,4.  A 4.2 cm cystic lesion of the right adnexa, correlation with pelvic ultrasound is advised.
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DESCRIPTION: Lower quadrant pain with nausea, vomiting, and diarrhea.  CT abdomen without contrast and CT pelvis without contrast.  Noncontrast axial CT images of the abdomen and pelvis are obtained.

gastroenterology, ct abdomen, ct pelvis, neoplasm, lesion, attenuation, hydronephrosis, stone formation, ct images, cystic lesion, abdomen, cystic, pancreatic, ct, pelvis, intravenous, noncontrast

The findings from the CT scan reveal potential issues that could indicate serious underlying health concerns, such as the cystic lesion in the pancreas that could be a neoplasm, and a large cystic lesion in the adnexal region. These findings require further investigation and could potentially lead to a cancer diagnosis, which is a high-stakes medical situation. The recommendation for follow-up imaging or biopsy underscores the seriousness, even though there's some degree of uncertainty without a contrast-enhanced study.


Medical Specialty: Gastroenterology
Sample Name: CT Abdomen & Pelvis

EXAM:,  CT Abdomen & Pelvis W&WO Contrast, ,REASON FOR EXAM: , Status post aortobiiliac graft repair. , ,TECHNIQUE: , 5 mm spiral thick spiral CT scanning was performed through the entire abdomen and pelvis utilizing intravenous dynamic bolus contrast enhancement.  No oral or rectal contrast was utilized.  Comparison is made with the prior CT abdomen and pelvis dated 10/20/05.  There has been no significant change in size of the abdominal aortic aneurysm centered roughly at the renal artery origin level which has dimensions of 3.7 cm transversely x 3.4 AP.  Just below this level is the top of the endoluminal graft repair with numerous surrounding surgical clips.  The size of the native aneurysm component at this level is stable at 5.5 cm in diameter with mural thrombus surrounding the enhancing endolumen.  There is no abnormal entrance of contrast agent into the mural thrombus to indicate an endoluminal leak.  Further distally, there is extension of the graft into both proximal common iliac arteries without evidence for endoluminal leak at this level either.  No exoluminal leakage is identified at any level.  There is no retroperitoneal hematoma present.  The findings are unchanged from the prior exam.  ,The liver, spleen, pancreas, adrenals and right kidney are unremarkable with moderate diffuse atrophy of the pancreas present.  There is advanced atrophy of the left kidney.  No hydronephrosis is present.  No acute findings are identified elsewhere in the abdomen. ,The lung bases are clear. ,Concerning the remainder of the pelvis, no acute pathology is identified.  There is prominent streak artifact from the left total hip replacement.  There is diffuse moderate sigmoid diverticulosis without evidence for diverticulitis.  The bladder grossly appears normal.  A hysterectomy has been performed.  ,IMPRESSION:,1.  No complications identified regarding endoluminal aortoiliac graft repair as described.  The findings are stable compared to the study of 10/20/04.  ,2.  Stable mild aneurysm of aortic aneurysm, centered roughly at renal artery level.  ,3.  No other acute findings noted. ,4.  Advanced left renal atrophy.
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DESCRIPTION: CT Abdomen & Pelvis W&WO Contrast

CT Abdomen & Pelvis W&WO Contrast

gastroenterology, aortobiiliac graft repair, renal atrophy, ct abdomen & pelvis, w&wo contrast, aortic aneurysm, renal artery, mural thrombus, endoluminal leak, ct abdomen, ct, contrast, pelvis, abdomen,

The given situation involves a follow-up medical imaging report for a patient who has undergone aortobiiliac graft repair. It describes the absence of acute or alarming findings, indicating a stable condition without complications from the procedure. The situation is not high-stakes because it primarily confirms the stability of previous medical findings without new critical issues. However, it involves monitoring an existing condition that could become serious if it changes, hence it is moderate in stakes.


Medical Specialty: Gastroenterology
Sample Name: Consult - Rectal Bleeding

PRESENT ILLNESS: , The patient is a very pleasant 69-year-old Caucasian male whom we are asked to see primarily because of a family history of colon cancer, but the patient also has rectal bleeding on a weekly basis and also heartburn once every 1 or 2 weeks.  The patient states that he had his first colonoscopy 6 years ago and it was negative.  His mother was diagnosed with colon cancer probably in her 50s, but she died of cancer of the esophagus at age 86.  The patient does have hemorrhoidal bleed about once a week.  Otherwise, he denies any change in bowel habits, abdominal pain, or weight loss.  He gets heartburn mainly with certain food such as raw onions and he has had it for years.  It will typically occur every couple of weeks.  He has had no dysphagia.  He has never had an upper endoscopy.,MEDICAL HISTORY: , Remarkable for hypertension, adult-onset diabetes mellitus, hyperlipidemia, and restless legs syndrome.,SURGICAL HISTORY: , Appendectomy as a child and cholecystectomy in 2003.,MEDICATIONS:  ,His medications are lisinopril 40 mg daily, hydrochlorothiazide 25 mg daily, metformin 1000 mg twice a day, Januvia 100 mg daily, clonazepam 10 mg at bedtime for restless legs syndrome, Crestor 10 mg nightly, and Flomax 0.4 mg daily.,ALLERGIES: , No known drug allergies.,SOCIAL HISTORY: , The patient is retired.  He is married.  He had 4 children.  He quite smoking 25 years ago after a 35-year history of smoking.  He does not drink alcohol.,FAMILY HISTORY: , Mother had colon cancer in her 50s, esophageal cancer in her 80s.  Her mother smoked and drank.  Father got a mesothelioma at age 65.  There is a brother of 65 with hypertension.,REVIEW OF SYSTEMS: , He has had prostatitis with benign prostatic hypertrophy.  He has some increased urinary frequency from a history of prostatitis.  He has the heartburn, which is diet dependent and the frequent rectal bleeding.  He also has restless legs syndrome at night.  No cardio or pulmonary complaints.  No weight loss.,PHYSICAL EXAMINATION: , Reveals a well-developed, well-nourished man in no acute distress.  BP 112/70.  Pulse 80 and regular.  Respirations non-labored.  Height 5 feet 7-1/2 inches.  Weight 209 pounds.  HEENT exam:  Sclerae are anicteric.  Pupils equal, conjunctivae clear.  No gross oropharyngeal lesions.  Neck is supple without lymphadenopathy, thyromegaly, or JVD.  Lungs are clear to percussion and auscultation.  Heart sounds are regular without murmur, gallop, or rub.  The abdomen is soft and nontender.  There are no masses.  There is no hepatosplenomegaly.  The bowel sounds are normal.  Rectal examination:  Deferred.  Extremities have no clubbing, cyanosis or edema.  Skin is warm and dry.  The patient is alert and oriented with a pleasant affect and no gross motor deficits.,IMPRESSION:,1.  Family history of colon cancer.,2.  Rectal bleeding.,3.  Heartburn and a family history of esophageal cancer.,PLAN:,  I agree with the indications for repeat colonoscopy, which should be done at least every 5 years.  Also, discussed IRC to treat bleeding and internal hemorrhoids if he is deemed to be an appropriate candidate at the time of his colonoscopy and the patient was agreeable.  I am also a little concerned about his family history of esophageal cancer and his personal history of heartburn and suggested that we check him once for Barrett's esophagus.  If he does not have it now then it should not be a significant risk in the future.  The indications and benefits of EGD, colonoscopy, and IRC were discussed.  The risks including sedation, bleeding, infection, and perforation were discussed.  The importance of a good bowel prep so as to minimize missing any lesions was discussed.  His questions were answered and informed consent obtained.  It was a pleasure to care for this nice patient.
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DESCRIPTION: Patient with family history of colon cancer and has rectal bleeding on a weekly basis and also heartburn once every 1 or 2 weeks.

gastroenterology, heartburn, family history of esophageal cancer, repeat colonoscopy, colonoscopy, egd, irc, barrett's esophagus, restless legs syndrome, esophageal cancer, rectal bleeding, colon cancer, rectal, bleeding, cancer,

The patient's situation involves potentially serious health concerns, including rectal bleeding and a family history of colon and esophageal cancer. These factors elevate the stakes due to the risk of life-threatening conditions. Furthermore, the need for repeat colonoscopy and checking for Barrett's esophagus demonstrates the serious nature of the follow-up and interventions required. Nonetheless, the patient currently presents no acute distress, and the required procedures are planned and measures discussed, which mitigates the immediate high-stakes aspect to an extent.


Medical Specialty: Gastroenterology
Sample Name: Consult - Screening Colonoscopy

HISTORY:,  A is a 55-year-old who I know well because I have been taking care of her husband.  She comes for discussion of a screening colonoscopy.  Her last colonoscopy was in 2002, and at that time she was told it was essentially normal.  Nonetheless, she has a strong family history of colon cancer, and it has been almost four to five years so she wants to have a repeat colonoscopy.  I told her that the interval was appropriate and that it made sense to do so.  She denies any significant weight change that she cannot explain.  She has had no hematochezia.  She denies any melena.  She says she has had no real change in her bowel habit but occasionally does have thin stools.,PAST MEDICAL HISTORY:,  On today's visit we reviewed her entire health history.  Surgically she has had a stomach operation for ulcer disease back in 1974, she says.  She does not know exactly what was done.  It was done at a hospital in California which she says no longer exists.  This makes it difficult to find out exactly what she had done.  She also had her gallbladder and appendix taken out in the 1970s at the same hospital.  Medically she has no significant problems and no true medical illnesses.  She does suffer from some mild gastroparesis, she says.,MEDICATIONS: , Reglan 10 mg once a day.,ALLERGIES: , She denies any allergies to medications but is sensitive to medications that cause her to have ulcers, she says.,SOCIAL HISTORY: , She still smokes one pack of cigarettes a day.  She was counseled to quit.  She occasionally uses alcohol.  She has never used illicit drugs.  She is married, is a housewife, and has four children.,FAMILY HISTORY: , Positive for diabetes and cancer.,REVIEW OF SYSTEMS: , Essentially as mentioned above.,PHYSICAL EXAMINATION:,GENERAL:  A is a healthy appearing female in no apparent distress.,VITAL SIGNS:  Her vital signs reveal a weight of 164 pounds, blood pressure 140/90, temperature of 97.6 degrees F.,HEENT:  No cervical bruits, thyromegaly, or masses.  She has no lymphadenopathy in the head and neck, supraclavicular, or axillary spaces bilaterally.,LUNGS:  Clear to auscultation bilaterally with no wheezes, rubs, or rhonchi.,HEART:  Regular rate and rhythm without murmur, rub, or gallop.,ABDOMEN:  Soft, nontender, nondistended.,EXTREMITIES:  No cyanosis, clubbing, or edema, with good pulses in the radial arteries bilaterally.,NEURO:  No focal deficits, is intact to soft touch in all four.,ASSESSMENT AND RECOMMENDATIONS: , In light of her history and physical, clearly the patient would be well served with an upper and lower endoscopy.  We do not know what the anatomy is, and if she did have an antrectomy, she needs to be checked for marginal ulcers.  She also complains of significant reflux and has not had an upper endoscopy in over five to six years as well.  I discussed the risks, benefits, and alternatives to upper and lower endoscopy, and these include over sedation, perforation, and dehydration, and she wants to proceed.,We will schedule her for an upper and lower endoscopy at her convenience.
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DESCRIPTION: Patient comes for discussion of a screening colonoscopy.

gastroenterology, screening colonoscopy, colonoscopy, hematochezia, screening, endoscopy,

The situation involves a medical assessment for a 55-year-old patient with a history of smoking, a strong family history of colon cancer, and a past medical history that includes surgeries and mild gastroparesis. A decision is made to perform an upper and lower endoscopy. The screening colonoscopy is necessary due to the patient's age, family history, and the time elapsed since her last colonoscopy. While screening for cancer is important, the patient is currently not showing alarming symptoms such as significant weight loss or gastrointestinal bleeding. The potential risks of the procedures are typical, and there is no indication of an urgent or life-threatening condition. Thus, while important, the situation is not extremely high-stakes.


Medical Specialty: Gastroenterology
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.

gastroenterology, mesothelioma, risk for colon cancer, constipation, diarrhea, multiple colon polyps, colon cancer, colon polyps, colon, cancer, polyps,

The situation involves a 50-year-old female with a family history of colon polyps, and symptoms indicating a potential risk for colon cancer and other significant gastrointestinal issues. This requires careful diagnosis and management, given the family risk factors and the multiple symptoms discussed. The prescribed plan includes procedures with potential complications that need to be managed thoughtfully, but there is no immediate life-threatening emergency, and the plan is designed to provide preventative care. Thus, while important, it is not life-threatening unless untreated over a longer period.


Medical Specialty: Gastroenterology
Sample Name: Colonoscopy with Biopsy - 4

PREOPERATIVE DIAGNOSIS: , Antibiotic-associated diarrhea.  ,POSTOPERATIVE DIAGNOSIS:  ,Antibiotic-associated diarrhea.  ,OPERATION PERFORMED: , Colonoscopy with random biopsies and culture.,INDICATIONS: , The patient is a 50-year-old woman who underwent hemorrhoidectomy approximately one year ago.  She has been having difficulty since that time with intermittent diarrhea and abdominal pain.  She states this happens quite frequently and can even happen when she uses topical prednisone for her ears or for her eyes.  She presents today for screening colonoscopy, based on the same.,OPERATIVE COURSE:  , The risks and benefits of colonoscopy were explained to the patient in detail.  She provided her consent.  The morning of the operation, the patient was transported from the preoperative holding area to the endoscopy suite.  She was placed in the left lateral decubitus position.  In divided doses, she was given 7 mg of Versed and 125 mcg of fentanyl.  A digital rectal examination was performed, after which time the scope was intubated from the anus to the level of the hepatic flexure.  This was intubated fairly easily; however, the patient was clearly in some discomfort and was shouting out, despite the amount of anesthesia she was provided.  In truth, the pain she was experiencing was out of proportion to any maneuver or difficulty with the procedure.  While more medication could have been given, the patient is actually a fairly thin woman and diminutive and I was concerned that giving her any more sedation may lead to respiratory or cardiovascular collapse.  In addition, she was really having quite some difficulty staying still throughout the procedure and was putting us all at some risk.  For this reason, the procedure was aborted at the level of the hepatic flexure.  She was noted to have some pools of stool.  This was suctioned and sent to pathology for C difficile, ova and parasites, and fecal leukocytes.  Additionally, random biopsies were performed of the colon itself.  It is unfortunate we were unable to complete this procedure, as I would have liked to have taken biopsies of the terminal ileum.  However, given the degree of discomfort she had, again, coupled with the relative ease of the procedure itself, I am very suspicious of irritable bowel syndrome.  The patient tolerated the remainder of the procedure fairly well and was sent to the recovery room in stable condition, where it is anticipated she will be discharged to home.,PLAN:,  She needs to follow up with me in approximately 2 weeks' time, both to follow up with her biopsies and cultures.  She has been given a prescription for VSL3, a probiotic, to assist with reculturing the rectum.  She may also benefit from an antispasmodic and/or anxiolytic.  Lastly, it should be noted that when she next undergoes endoscopic procedure, propofol would be indicated.
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DESCRIPTION: Colonoscopy with random biopsies and culture.

gastroenterology, colonoscopy with random biopsies, hepatic flexure, topical, culture, antibiotic, hepatic, flexure, diarrhea, biopsies, colonoscopy

The situation involves performing a medical procedure (colonoscopy) to diagnose and manage a patient with antibiotic-associated diarrhea. The procedure was not completed due to the patient's distress and discomfort, raising the suspicion of irritable bowel syndrome. While this is a significant diagnostic situation, it is not immediately life-threatening or time-critical. The patient was stable and is expected to follow up in two weeks. However, it requires careful management to ensure correct diagnosis and treatment. Given this context, the stakes are moderate since the condition impacts the patient's quality of life but is not acutely life-threatening.


Medical Specialty: Gastroenterology
Sample Name: Colonoscopy with Biopsy - 3

PREPROCEDURE DIAGNOSIS: , Abdominal pain, diarrhea, and fever.,POSTPROCEDURE DIAGNOSIS: , Pending pathology.,PROCEDURES PERFORMED: , Colonoscopy with multiple biopsies, including terminal ileum, cecum, hepatic flexure, and sigmoid colon.
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DESCRIPTION: Colonoscopy with multiple biopsies, including terminal ileum, cecum, hepatic flexure, and sigmoid colon.

gastroenterology, colonoscopy with multiple biopsies, length of the colon, diarrhea and fever, terminal ileum cecum, multiple biopsies, ileum cecum, cecum hepatic, hepatic flexure, terminal ileum, sigmoid colon, colonoscopy, diarrhea, cecum, hepatic, flexure, inflammation, biopsies, terminal, ileum, sigmoid, scope,

The procedure involves a colonoscopy with multiple biopsies, which indicates a thorough investigation due to symptoms like abdominal pain, diarrhea, and fever. These symptoms, along with the fact that pathology is pending to determine further diagnosis, suggests the stakes are moderate to high, depending on potential pathological findings. However, without immediate life-threatening symptoms or conditions present, the stakes are not at the maximum level.


Medical Specialty: Gastroenterology
Sample Name: Colonoscopy with Biopsy - 2

PROCEDURE PERFORMED: , Colonoscopy and biopsy.,INDICATIONS:,  The patient is a 50-year-old female who has had a history of a nonspecific colitis, who was admitted 3 months ago at Hospital because of severe right-sided abdominal pains, was found to have multiple ulcers within the right colon, and was then readmitted approximately 2 weeks later because of a cecal volvulus, and had a right hemicolectomy.  Since then, she has had persistent right abdominal pains, as well as diarrhea, with up to 2-4 bowel movements per day.  She has had problems with recurrent seizures and has been seen by Dr. XYZ, who started her recently on methadone.,MEDICATIONS: , Fentanyl 200 mcg, Versed 10 mg, Phenergan 25 mg intravenously given throughout the procedure.,INSTRUMENT: , PCF-160L.,PROCEDURE REPORT: , Informed consent was obtained from the patient, after the risks and benefits of the procedure were carefully explained, which included but were not limited to bleeding, infection, perforation, and allergic reaction to the medications, as well as the possibility of missing polyps within the colon.,A colonoscope was then passed through the rectum, all the way toward the ileal colonic anastomosis, seen within the proximal transverse colon.  The distal ileum was examined, which was normal in appearance.  Random biopsies were obtained from the ileum and placed in jar #1.  Random biopsies were obtained from the normal-appearing colon and placed in jar #2.  Small internal hemorrhoids were noted within the rectum on retroflexion.,COMPLICATIONS: , None.,ASSESSMENT:,1.  Small internal hemorrhoids.,2.  Ileal colonic anastomosis seen in the proximal transverse colon.,3.  Otherwise normal colonoscopy and ileum examination.,PLAN:, Followup results of biopsies.  If the biopsies are unremarkable, the patient may benefit from a trial of tricyclic antidepressants, if it's okay with Dr. XYZ, for treatment of her chronic abdominal pains.
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DESCRIPTION: Small internal hemorrhoids and Ileal colonic anastomosis.

gastroenterology, proximal transverse, transverse colon, internal hemorrhoids, colonic anastomosis, biopsy, rectum, transverse, hemorrhoids, colonic, anastomosis, abdominal, ileum, biopsies, colonoscopy

The case involves a colonoscopy with biopsy on a patient with a complex medical history, including previous severe conditions (such as cecal volvulus and hemicolectomy) and ongoing symptoms. While the procedure itself is routine, the potential findings from the biopsy could impact the patient's treatment plan significantly. There are no immediate complications, which reduces the immediate stakes, but given the patient's history and the potential need for adjusting treatment (possibly introducing antidepressants), there are important decisions and monitoring required post-procedure.


Medical Specialty: Gastroenterology
Sample Name: Colonoscopy - 20

PREOPERATIVE DIAGNOSIS: , Screening. ,POSTOPERATIVE DIAGNOSIS:,  Tiny Polyps.,PROCEDURE PERFORMED:  , Colonoscopy.,PROCEDURE:  , The procedure, indications, and risks were explained to the patient, who understood and agreed.  He was sedated with Versed 3 mg, Demerol 25 mg during the examination.  ,A digital rectal exam was performed and the Pentax Video Colonoscope was advanced over the examiner's finger into the rectum.  It was passed to the level of the cecum.  The ileocecal valve was identified, as was the appendiceal orifice.  ,Slowly withdrawal through the colon revealed a small polyp in the transverse colon.  This was approximately 3 mm in size and was completely removed using multiple bites with cold biopsy forceps.  In addition, there was a 2 mm polyp versus lymphoid aggregate in the descending colon.  This was also removed using the cold biopsy forceps.  Further detail failed to reveal any other lesions with the exception of small hemorrhoids.  ,IMPRESSION:  , Tiny polyps.  ,PLAN:  , If adenomatous, repeat exam in five years.  Otherwise, repeat exam in 10 years.,
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DESCRIPTION: Screening colonoscopy.  Tiny polyps.   If adenomatous, repeat exam in five years.

gastroenterology, pentax video colonoscope, biopsy forceps, tiny polyps, polyps, adenomatous, colonoscopy

The situation involves a routine medical procedure, a colonoscopy, which was conducted for screening purposes. The patient was found to have tiny polyps, which is a fairly common finding. They were successfully removed during the procedure, and the plan involves a follow-up based on whether the polyps are adenomatous. While health-related, the stakes are not immediately critical since the follow-up plan is routine, and the findings do not indicate any immediate grave health threats.


Medical Specialty: Gastroenterology
Sample Name: Colonoscopy - 17

PREOPERATIVE DIAGNOSIS: , Colon polyps.,POSTOPERATIVE DIAGNOSES:,1.  Universal diverticulosis.,2.  Nonsurgical internal hemorrhoids.,PROCEDURE PERFORMED:, Total colonoscopy with photos.,ANESTHESIA:,  Demerol 100 mg IV with Versed 3 mg IV.,SPECIMENS: , None.,ESTIMATED BLOOD LOSS: , Minimal.,INDICATIONS FOR PROCEDURE:  ,The patient is a 62-year-old white male who presents to the office with a history of colon polyps and need for recheck.,PROCEDURE:,  Informed consent was obtained.  All risks and benefits of the procedure were explained and all questions were answered.  The patient was brought back to the Endoscopy Suite where he was connected to cardiopulmonary monitoring.  Demerol 100 mg IV and Versed 3 mg IV was given in a titrated fashion until appropriate anesthesia was obtained.  Upon appropriate anesthesia, a digital rectal exam was performed, which showed no masses.  The colonoscope was then placed into the anus and the air was insufflated.  The scope was then advanced under direct vision into the rectum, rectosigmoid colon, descending colon, transverse colon, ascending colon until it reached the cecum.  Upon entering the sigmoid colon and throughout the rest of the colon, there was noted diverticulosis.  After reaching the cecum, the scope was fully withdrawn visualizing all walls again noting universal diverticulosis.,Upon reaching the rectum, the scope was then retroflexed upon itself and there was noted to be nonsurgical internal hemorrhoids.  The scope was then subsequently removed.  The patient tolerated the procedure well and there were no complications.
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DESCRIPTION: Universal diverticulosis and nonsurgical internal hemorrhoids. Total colonoscopy with photos.  The patient is a 62-year-old white male who presents to the office with a history of colon polyps and need for recheck.

gastroenterology, endoscopy, rectum, rectosigmoid colon, descending colon, transverse colon, ascending colon, total colonoscopy, colon polyps, colonoscopy, cecum, polyps, diverticulosis, hemorrhoids,

The procedure described is a standard colonoscopy, which is a routine, low-risk procedure often performed for screening or surveillance of colon health, especially in patients with a history of colon polyps. The report indicates that the procedure went smoothly, with minimal blood loss and no complications. The findings of universal diverticulosis and nonsurgical internal hemorrhoids are common and typically not immediately life-threatening. Given the context, this is a low-stakes situation.


Medical Specialty: Gastroenterology
Sample Name: Colonoscopy - 18

PREOPERATIVE DIAGNOSIS: , Possible inflammatory bowel disease.,POSTOPERATIVE DIAGNOSIS: , Polyp of the sigmoid colon.,PROCEDURE PERFORMED:  ,Total colonoscopy with photography and polypectomy.,GROSS FINDINGS: , The patient had a history of ischiorectal abscess.  He has been evaluated now for inflammatory bowel disease.  Upon endoscopy, the colon prep was good.  We were able to reach the cecum without difficulty.  There are no diverticluli, inflammatory bowel disease, strictures, or obstructing lesions.  There was a pedunculated polyp approximately 4.5 cm in size located in the sigmoid colon at approximately 35 cm.  This large polyp was removed using the snare technique.,OPERATIVE PROCEDURE:  ,The patient was taken to the endoscopy suite, prepped and draped in left lateral decubitus position.  IV sedation was given by Anesthesia Department.  The Olympus videoscope was inserted into anus.  Using air insufflation, the colonoscope was advanced through the anus to the rectum, sigmoid colon, descending colon, transverse colon, ascending colon and cecum, the above gross findings were noted.  The colonoscope was slowly withdrawn and carefully examined the lumen of the bowel.  When the polyp again was visualized, the snare was passed around the polyp.  It required at least two to three passes of the snare to remove the polyp in its totality.  There was a large stalk on the polyp.  ________ the polyp had been removed down to the junction of the polyp in the stalk, which appeared to be cauterized and no residual adenomatous tissue was present.  No bleeding was identified.  The colonoscope was then removed and patient was sent to recovery room in stable condition.
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DESCRIPTION: Possible inflammatory bowel disease.  Polyp of the sigmoid colon..  Total colonoscopy with photography and polypectomy.

gastroenterology, polypectomy, inflammatory bowel disease, sigmoid colon, rectum, descending colon, transverse colon, ascending colon, cecum, total colonoscopy, bowel disease, inflammatory, polyp, colonoscopy, colonoscope, bowel,

The situation involves a medical procedure, specifically a colonoscopy, which identifies and removes a polyp in the sigmoid colon and rules out inflammatory bowel disease. While there is always some level of risk and importance inherent in medical procedures, this appears to be a routine diagnostic and therapeutic colonoscopy conducted to address a non-cancerous concern. No complications were noted, the patient is stable, and inflammatory bowel disease was ruled out, indicating a successful procedure. These factors suggest that the stakes are moderate, not extremely high or low.


Medical Specialty: Gastroenterology
Sample Name: Colonoscopy - 12

PROCEDURE IN DETAIL: , Following instructions and completion of an oral colonoscopy prep, the patient, having been properly informed of, with signature consenting to total colonoscopy and indicated procedures, the patient received premedications of Vistaril 50 mg, Atropine 0.4 mg IM, and then intravenous medications of Demerol 50 mg and Versed 5 mg IV.  Perirectal inspection was normal.  The Olympus video colonoscope then was introduced into the rectum and passed by directed vision to the cecum and into the terminal ileum.  No abnormalities were seen of the terminal ileum, the ileocecal valve, cecum, ascending colon, hepatic flexure, transverse colon, splenic flexure, descending colon, rectosigmoid and rectum.  Retroflexion exam in the rectum revealed no other abnormality and withdrawal terminated the procedure.
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DESCRIPTION: Colonoscopy.  The Olympus video colonoscope then was introduced into the rectum and passed by directed vision to the cecum and into the terminal ileum.

gastroenterology, ileocecal valve, cecum, ascending colon, hepatic flexure, transverse colon, splenic flexure, descending colon, rectosigmoid, rectum, terminal ileum, olympus video colonoscope, flexure, colonoscopyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

The procedure described is a colonoscopy, which is a routine diagnostic test conducted to examine the interior of the colon and rectum. Although it is a common procedure, it is invasive and requires sedation, thus involving certain risks like bleeding, perforation, or adverse reactions to medication. However, the details given indicate that this was a standard colonoscopy with no complications or abnormalities found, which suggests this specific case was low-risk. The stakes could be higher if complications occurred or if significant findings were discovered, but this was not the case here.


Medical Specialty: Gastroenterology
Sample Name: Colonoscopy

PREOPERATIVE DIAGNOSIS:,  Iron deficiency anemia.,POSTOPERATIVE DIAGNOSIS:,  Diverticulosis.,PROCEDURE:,  Colonoscopy.,MEDICATIONS: , MAC.,PROCEDURE: , The Olympus pediatric variable colonoscope was introduced into the rectum and advanced carefully through the colon to the cecum identified by the ileocecal valve and the appendiceal orifice.  Preparation was good, although there was some residual material in the cecum that was difficult to clear completely.  The mucosa was normal throughout the colon.  No polyps or other lesions were identified, and no blood was noted.  Some diverticula were seen of the sigmoid colon with no luminal narrowing or evidence of inflammation.  A retroflex view of the anorectal junction showed no hemorrhoids.  The patient tolerated the procedure well and was sent to the recovery room.,FINAL DIAGNOSES:,1.  Diverticulosis in the sigmoid.,2.  Otherwise normal colonoscopy to the cecum.,RECOMMENDATIONS:,1.  Follow up with Dr. X as needed.,2.  Screening colonoscopy in 2 years.,3.  Additional evaluation for other causes of anemia may be appropriate.
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DESCRIPTION: Iron deficiency anemia.  Diverticulosis in the sigmoid.

gastroenterology, olympus, colonoscope, iron deficiency anemia, diverticulosis, sigmoid, cecum, anemia, colonoscopy

The situation involves a medical procedure and diagnosis related to a potentially serious health condition, iron deficiency anemia, which can indicate other underlying health problems. However, the colonoscopy results were mostly normal, with findings of diverticulosis which are common and typically non-threatening without complications. Recommendations for future screenings and evaluations were routine, indicating no immediate life-threatening issues. This is a moderate stakes scenario in a medical context, relating more to ongoing health management than acute critical care.