Medical Specialty: Surgery
Sample Name: Radical Hysterectomy

PREOPERATIVE DIAGNOSIS:,  Cervical adenocarcinoma, stage I.,POSTOPERATIVE DIAGNOSIS: , Cervical adenocarcinoma, stage I.,OPERATION PERFORMED:,  Exploratory laparotomy, radical hysterectomy, bilateral ovarian transposition, pelvic and obturator lymphadenectomy.,ANESTHESIA: , General, endotracheal tube.,SPECIMENS: , Uterus with attached parametrium and upper vagina, right and left pelvic and obturator lymph nodes.,INDICATIONS FOR PROCEDURE:,  The patient recently underwent a cone biopsy at which time invasive adenocarcinoma of the cervix was noted.  She was advised regarding treatment options including radical hysterectomy versus radiation and the former was recommended. ,FINDINGS: , During the examination under anesthesia, the cervix was noted to be healing well from recent cone biopsy and no nodularity was noted in the supporting ligaments.  During the exploratory laparotomy, there was no evidence of disease extension into the broad ligament or bladder flap.  There was no evidence of intraperitoneal spread or lymphadenopathy.  ,OPERATIVE PROCEDURE:  ,The patient was brought to the Operating Room with an IV in place.  Anesthetic was administered after which she was examined under anesthesia.  The vagina was then prepped and a Foley catheter was placed.  She was prepped and draped.  A Pfannenstiel incision was made three centimeters above the symphysis pubis.  The peritoneum was entered and the abdomen was explored with findings as noted.  The Bookwalter retractor was placed, and bowel was packed.  Clamps were placed on the broad ligament for traction.  The retroperitoneum was opened by incising lateral and parallel to the infundibulopelvic ligaments.  The round ligaments were isolated, divided and ligated.  The peritoneum overlying the vesicouterine fold was incised, and the bladder was mobilized using sharp dissection.  The pararectal and paravesical spaces were opened, and the broad ligament was palpated with no evidence of suspicious findings or disease extension.  The utero-ovarian ligaments were then isolated, divided and doubly ligated.  Tubes and ovaries were mobilized.  The ureters were dissected free from the medial leaf of the peritoneum.  When the crossover of the uterine artery was reached, and the artery was isolated at its origin, divided and ligated.  The uterine artery pedicle was dissected anteriorly over the ureter.  The ureter was tunneled through the broad ligament using right angle clamps for tunneling after which each pedicle was divided and ligated.  This was continued until the insertion point of the ureter into the bladder trigone.  The peritoneum across the cul-de-sac was divided, and the rectovaginal space was opened.  Clamps were placed on the uterosacral ligaments at their point of origin.  Tissues were divided and suture ligated.  Clamps were placed on the paravaginal tissues, which were then divided, and suture ligated.  The vagina was then clamped and divided at the junction between the middle and upper third.  The vaginal vault was closed with interrupted figure-of-eight stitches.  Excellent hemostasis was noted.,Retractors were repositioned in the retroperitoneum for the lymphadenectomy.  The borders of dissection included the bifurcation of the common iliac artery superiorly, the crossover of the deep circumflex iliac vein over the external iliac artery inferiorly, the psoas muscle laterally and the anterior division of the hypogastric artery medially.  The obturator nerves were carefully isolated and preserved bilaterally and served as the posterior border of dissection.  Ligaclips were applied where necessary.  After removal of the lymph node specimens, the pelvis was irrigated.  The ovaries were transposed above the pelvic brim using running stitches.  Packs and retractors were removed, and peritoneum was closed with a running stitch.  Subcutaneous tissues were irrigated, and fascia was closed with a running mass stitch using delayed absorbable suture.  Subcutaneous adipose was irrigated, and Scarpa's fascia was closed with a running stitch.  Skin was closed with a running subcuticular stitch.  Final sponge, needle, and instrument counts were correct at the completion of the procedure.  The patient was awakened from the anesthetic and taken to the Post Anesthesia Care Unit in stable condition.
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DESCRIPTION: Exploratory laparotomy, radical hysterectomy, bilateral ovarian transposition, pelvic and obturator lymphadenectomy.

surgery, cervical adenocarcinoma, radical hysterectomy, exploratory laparotomy, bilateral ovarian transposition, lymphadenectomy, parametrium, cervix, pelvic and obturator lymphadenectomy, pelvic and obturator, obturator lymphadenectomy, laparotomy, ovarian, adenocarcinoma, radical, hysterectomy, pelvic, obturator, peritoneum, nodes, ligaments

The procedure described is a radical hysterectomy, which is a significant surgical intervention for cervical cancer. This type of surgery is performed when cervical cancer is diagnosed and involves removing the uterus, surrounding tissues, and often lymph nodes to ensure the cancer hasn't spread. Such a procedure carries potential risks and complications, including those associated with general anesthesia, major surgery, and potential impacts on fertility and hormonal balance due to ovarian transposition. The stakes are high because it involves treating a potentially life-threatening condition (cervical cancer), requires meticulous surgical technique to prevent complications, and has long-term health implications for the patient.


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

Medical Specialty: General Medicine
Sample Name: Acute Cystitis & Diabetes Type II

HISTORY OF PRESENT ILLNESS: , The patient is a 45-year-old male complaining of abdominal pain.  The patient also has a long-standing history of diabetes which is treated with Micronase daily.,PAST MEDICAL HISTORY: , There is no significant past medical history noted today.,PHYSICAL EXAMINATION:,HEENT:  Patient denies ear abnormalities, nose abnormalities and throat abnormalities.,Cardio:  Patient has history of elevated cholesterol, but does not have ASHD, hypertension and PVD.,Resp:  Patient denies asthma, lung infections and lung lesions.,GI:  Patient denies colon abnormalities, gall bladder problems, liver abnormalities and peptic ulcer disease.,GU:  Patient has history of Urinary tract disorder, but does not have Bladder disorder and Kidney disorder.,Endocrine:  Patient has history of diabetes, but does not have hormonal irregularities and thyroid abnormalities.,Dermatology:  Patient denies allergic reactions, rashes and skin lesions.,MEDS:,  Micronase 2.5 mg Tab PO QAM #30.  Bactrim 400/80 Tab PO BID #30.,SOCIAL HISTORY:,  No known history of drug or alcohol abuse.  Work, diet, and exercise patterns are within normal limits.,FAMILY HISTORY:,  No significant family history.,REVIEW OF SYSTEMS:,  Non-contributory.,Vital Signs:  Height = 72 in.  Weight =184 lbs.  Upright BP = 120/80 mmHg.  Pulse = 80 bpm.  Resp =12 pm.  Patient is afebrile.,Neck:  The neck is supple.  There is no jugular venous distension.  The thyroid is nontender, or normal size and conto.,Lungs:  Lung expansion and excursions are symmetric.  The lungs are clear to auscultation and percussion.,Cardio:  There is a regular rhythm.  SI and S2 are normal.  No abnormal heart sounds are detected.  Blood pressure is equal bilaterally.,Abdomen:  Normal bowel sounds are present.  The abdomen is soft; The abdomen is nontender; without organomegaly; There is no CVA tenderness.  No hernias are noted.,Extremities:  There is no clubbing, cyanosis, or edema.,ASSESSMENT: , Diabetes type II uncontrolled.  Acute cystitis.,PLAN: , Endocrinology Consult, complete CBC.  ,RX: , Micronase 2.5 mg Tab PO QAM #30, Bactrim 400/80 Tab PO BID #30.
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DESCRIPTION: The patient complaining of abdominal pain, has a long-standing history of diabetes treated with Micronase daily.

This case involves a 45-year-old male with both uncontrolled Type II diabetes and acute cystitis. Diabetes, particularly when uncontrolled, can lead to serious complications like cardiovascular disease, nerve damage, and kidney damage. Additionally, acute cystitis, while often straightforward to treat with antibiotics, can pose a risk for further complications like kidney infections, particularly in diabetic patients. This requires careful monitoring and management, especially given the patient's chronic condition. Therefore, the stakes are moderately high due to the potential for complications and the need for ongoing management.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Cardioversion - Unsuccessful

REASON FOR EXAM: , Atrial flutter/cardioversion.,PROCEDURE IN DETAIL: , The procedure was explained to the patient with risks and benefits.  The patient agreed and signed the consent form.  The patient received sedation prior to the cardioversion with a transesophageal echo as dictated earlier with a total of 50 mcg of fentanyl and 6 mg of Versed.  The pads were applied in the anterior-posterior approach.  The synchronized cardioversion with biphasic energy delivered at 150 J. First attempt was unsuccessful.  Second attempt at 200 J with anterior-posterior approach.  With biphasic synchronized energy delivered was also unsuccessful with degeneration of the atrial flutter into atrial fibrillation.,The patient was decided to be on wave control and amiodarone and reattempted cardioversion after anticoagulation for four to six weeks and because of the reduced LV function, the success of the rate without antiarrhythmic may be low.,IMPRESSION: , Unsuccessful direct current cardioversion with permanent atrial fibrillation.
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DESCRIPTION: Cardioversion.  Unsuccessful direct current cardioversion with permanent atrial fibrillation.

cardiovascular / pulmonary, atrial flutter, cardioversion, anterior-posterior, transesophageal, atrial fibrillation, flutter/cardioversion, fibrillation, atrial,

The case involves a failed cardioversion procedure, which is an attempt to restore normal heart rhythm, an essential aspect of cardiovascular treatment. The unsuccessful procedure has led to permanent atrial fibrillation. Although this is a serious situation, it is not immediately life-threatening if managed properly with medication and scheduled follow-up procedures. Thus, while it necessitates careful management and follow-up, it doesn't pose an immediate life-or-death scenario at this moment.


Medical Specialty: Dermatology
Sample Name: Excision - Keratotic Neoplasm

PREOPERATIVE DIAGNOSES:,1.  Enlarging dark keratotic lesion of the left temple measuring 1 x 1 cm.,2.  Enlarging keratotic neoplasm of the left nasolabial fold measuring 0.5 x 0.5 cm.,3.  Enlarging seborrheic keratotic neoplasm of the right temple measuring 1 x 1 cm.,POSTOPERATIVE DIAGNOSES:,1.  Enlarging dark keratotic lesion of the left temple measuring 1 x 1 cm.,2.  Enlarging keratotic neoplasm of the left nasolabial fold measuring 0.5 x 0.5 cm.,3.  Enlarging seborrheic keratotic neoplasm of the right temple measuring 1 x 1 cm.,TITLE OF PROCEDURES:,1.  Excision of the left temple keratotic neoplasm, final defect 1.8 x 1.5 cm with two layer plastic closure.,2.  Excision of the left nasolabial fold defect 0.5 x 0.5 cm with single layer closure.,3.  Excision of the right temple keratotic neoplasm, final defect measuring 1.5 x 1.5 cm with two layer plastic closure.,ANESTHESIA: , Local using 3 mL of 1% lidocaine with 1:100,000 epinephrine.,ESTIMATED BLOOD LOSS: , Less than 30 mL.,COMPLICATIONS:,  None.,PROCEDURE: , The patient was evaluated preoperatively and noted to be in stable condition.  Informed consent was obtained from the patient.  All risks, benefits and alternatives regarding the surgery have been reviewed in detail with the patient.  This includes risks of bleeding, infection, scarring, recurrence of lesion, need for further procedures, etc.  Each of the areas was cleaned with a sterile alcohol swab.  Planned excision site was marked with a marking pen.  Local anesthetic was infiltrated.  Sterile prep and drape were then performed.,We began first with excision of the left temple followed by the left nasolabial and right temple lesions.  The left temple lesion is noted to be a dark black what appears to be a keratotic or possible seborrheic keratotic neoplasm.  However, it is somewhat deeper than the standard seborrheic keratosis.  The incision for removal of this lesion was placed within the relaxed skin tension line of the left temple region.  Once this was removed, wide undermining was performed and the wound was closed in a two layer fashion using 5-0 myochromic for the deep subcutaneous and 5-0 nylon for the skin.,Excision of left cheek was a keratotic nevus.  It was excised with a defect 0.5 x 0.5 cm.  It was closed in a single layer fashion 5-0 nylon.,The lesion of the right temple also dark black keratotic neoplasm was excised with the incision placed within the relaxed skin tension.  Once it was excised full-thickness, the defect measure 1.5 x 1.5 cm.  Wide undermine was performed and it was closed in a two layer fashion using 5-0 myochromic for the deep subcutaneous, 5-0 nylon that was used to close skin.  Sterile dressing was applied afterwards.  The patient was discharged in stable condition.  Postop care instructions reviewed in detail.  She is scheduled with me in one week and we will make further recommendations at that time.
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DESCRIPTION: Excision of the left temple keratotic neoplasm and left nasolabial fold defect and right temple keratotic neoplasm.

dermatology, keratotic lesion, keratotic neoplasm, seborrheic keratotic neoplasm, seborrheic, keratotic, neoplasm, nasolabial, two layer plastic closure, nasolabial fold, excision,

The situation described involves the excision of keratotic neoplasms, which are typically benign skin growths like seborrheic keratosis. While the procedure requires precision and care, it is commonly performed under local anesthesia with minimal blood loss and no complications noted. The absence of any major complications and the benign nature of the lesions suggest this is not an especially high-stakes medical situation.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Intrauterine Pregnancy - Discharge Summary

ADMITTING DIAGNOSIS:,  Intrauterine pregnancy at term with previous cesarean.,SECONDARY DIAGNOSIS: , Desired sterilization.,DISCHARGE DIAGNOSES,1.  Intrauterine pregnancy at term with previous cesarean.,2.  Desired sterilization.,3.  Status post repeat low transverse cesarean and bilateral tubal ligation.,HISTORY: , The patient is a 35-year-old gravida 2, para 1-0-0-1 with intrauterine pregnancy on 08/30/09.  Pregnancy was uncomplicated.  She opted for a scheduled elective C-section and sterilization without any trial of labor.  All routine screening labs were normal and she underwent a high-resolution ultrasound during pregnancy.,PAST MEDICAL HISTORY: , Significant for postpartum depression after her last baby as well as a cesarean.,ALLERGIES:,  SHE HAS SEASONAL ALLERGIES.,MEDICATIONS:,  She is taking vitamins and iron.,PHYSICAL EXAMINATION,GENERAL:  An alert gravid woman in no distress.,ABDOMEN:  Gravid, nontender, non-irritable, with an infant in the vertex presentation.  Estimated fetal weight was greater than 10 pounds.,HOSPITAL COURSE:  ,On the first hospital day, the patient went to the operating room where repeat low transverse cesarean and tubal ligation were performed under spinal anesthesia with delivery of a viable female infant weighing 7 pounds 10 ounces and Apgars of 9 and 9.  There was normal placenta, normal pelvic anatomy.  There was 600 cc estimated blood loss.  Patient recovered uneventfully from her anesthesia and surgery.  She was able to ambulate and void.  She tolerated regular diet.  She passed flatus.  She was breast-feeding.  Postoperative hematocrit was 31.  On the second postoperative day, the patient was discharged home in satisfactory condition.,DISCHARGE MEDICATIONS: , Motrin and Percocet for pain.  Paxil for postpartum depression.  She was instructed to do no lifting, straining, or driving, to put nothing in the vagina and to see me in two weeks or with signs of severe pain, heavy bleeding, fever, or other problems.
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DESCRIPTION: Intrauterine pregnancy at term with previous cesarean.   Desired sterilization.  Status post repeat low transverse cesarean and bilateral tubal ligation.

obstetrics / gynecology, cesarean, bilateral tubal ligation, low transverse cesarean, intrauterine, gravida, sterilization, pregnancy,

This situation involves a medical procedure of moderate complexity - a cesarean section and sterilization, both of which carry inherent risks and require proper postoperative care. However, the discharge summary indicates that the surgery proceeded without complications, the patient and baby are in good health, and there are clear postoperative instructions to mitigate risk. Thus, while it requires professional medical attention, it is not an emergency or critical situation, especially since the patient is discharged in satisfactory condition.


Medical Specialty: Pain Management
Sample Name: Hip Injection

PROCEDURE: , Hip injection.,INFORMED CONSENT:  ,The risks, benefits and alternatives of the procedure were discussed with the patient.  The patient was given opportunity to ask questions regarding the procedure, its indications and the associated risks.,The risk of the procedure discussed include infection, bleeding, allergic reaction, dural puncture, headache, nerve injuries, spinal cord injury, and cardiovascular and CNS side effects with possible of vascular entry of medications.  I also informed the patient of potential side effects or reactions to the medications potentially used during the procedure including sedatives, narcotics, nonionic contrast agents, anesthetics, and corticosteroids.,The patient was informed both verbally and in writing.  The patient understood the informed consent and desired to have the procedure performed.,PROCEDURE:  ,Oxygen saturation and vital signs were monitored continuously throughout the procedure.  The patient remained awake throughout the procedure in order to interact and give feedback.  The X-ray technician was supervised and instructed to operate the fluoroscopy machine.,The patient was placed in the prone position on the treatment table.  The skin over and surrounding the treatment area was cleaned with Betadine.  The area was covered with sterile drapes, leaving a small window opening for needle placement.  Fluoroscopy was used to identify the boney landmarks of the hip and the planned needle approach.  The femoral artery was located by palpation of the pulse.  The skin, subcutaneous tissue, and muscle within the planned needle approach were anesthetized with 1% Lidocaine.  All injected medications were preservative free.  With fluoroscopy, a *** spinal needle was gently guided into the ***.  Multiple fluoroscopic views were used to ensure proper needle placement.  Approximately *** nonionic contrast agent was injected under direct real-time fluoroscopic observation.  Correct needle placement was confirmed by production of an appropriate arthrogram without concurrent vascular dye pattern.  Finally, the treatment solution, consisting of ***.  All injected medications were preservative free.  Sterile technique was used throughout the procedure,COMPLICATIONS: , None.  No complications.  The patient tolerated the procedure well and was sent to the recovery room in good condition.,DISCUSSION: , Post-procedure vital signs and oximetry were stable.  The patient was discharged with instructions to ice the injection site as needed for 15-20 minutes as frequently as twice per hour for the next day and to avoid aggressive activities for 1 day.  The patient was told to resume all medications.  The patient was told to be in relative rest for 1 day but then could resume all normal activities.,The patient was instructed to seek immediate medical attention for shortness of breath, chest pain, fever, chills, increased pain, weakness, sensory or motor changes, or changes in bowel or bladder function.,Follow up appointment was made in approximately 1 week.
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DESCRIPTION: Hip injection.  Fluoroscopy was used to identify the boney landmarks of the hip and the planned needle approach.  The femoral artery was located by palpation of the pulse.  The skin, subcutaneous tissue, and muscle within the planned needle approach were anesthetized with 1% Lidocaine.

pain management, boney landmarks, fluoroscopy, femoral artery, planned needle approach, hip injection, injection, hip, needle

The procedure described is a hip injection, which is a relatively common pain management technique. While there are several serious potential risks mentioned (e.g., infection, bleeding, nerve injuries, spinal cord injury), these are typical risks associated with invasive procedures, especially those involving injections near major structures. The informed consent process appears thorough, and the procedure itself is described as having no complications. The patient was stable post-procedure, and proper aftercare instructions were given. While any medical procedure carries inherent risks, the steps taken indicate standard practice in mitigating these risks. Therefore, while the situation is medically significant, it does not reach the highest level of stakes as it is a controlled and standard procedure.


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

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

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

The situation involves a 26-year-old patient with a neurological condition known as lateral medullary syndrome resulting from a left vertebral artery dissection. This condition has led to significant symptoms including difficulties with walking, sensory abnormalities, and cranial nerve issues such as Horner's syndrome and vocal cord paralysis. The patient has undergone various diagnostic procedures, including a cerebral angiogram confirming the dissection, and is on anticoagulation therapy. This is a high-stakes scenario due to the potential for stroke advancement, cranial nerve dysfunction, and the need for precise management of anticoagulation therapy to prevent further vascular events.


Medical Specialty: ENT - Otolaryngology
Sample Name: Adenotonsillectomy - 1

PREOPERATIVE DIAGNOSIS: , Recurrent tonsillitis.,POSTOPERATIVE DIAGNOSIS: , Recurrent tonsillitis.,PROCEDURE:  ,Adenotonsillectomy.,COMPLICATIONS:,  None.,PROCEDURE DETAILS:, The patient was brought to the operating room and, under general endotracheal anesthesia in supine position, the table turned and a McIvor mouthgag placed.  The adenoid bed was examined and was moderately hypertrophied.  Adenoid curettes were used to remove this tissue and packs placed.  Next, the right tonsil was grasped with a curved Allis and, using the gold laser, the anterior tonsillar pillar incised and, with this laser, dissection carried from the superior pole to the inferior pole and removed off the tonsillar muscular bed.  A similar procedure was performed on the contralateral tonsil.  Following meticulous hemostasis, saline was used to irrigate and no further bleeding noted.  The patient was then allowed to awaken and was brought to the recovery room in stable condition.
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DESCRIPTION: Adenotonsillectomy.  Recurrent tonsillitis.  The adenoid bed was examined and was moderately hypertrophied.  Adenoid curettes were used to remove this tissue and packs placed.

ent - otolaryngology, curved allis, tonsillitis, hypertrophied, curettes, tonsillar, adenoid, adenotonsillectomy,

The situation involves a routine adenotonsillectomy procedure for recurrent tonsillitis, which is a common ENT surgery. The documentation indicates that there were no complications and the patient was in stable condition post-surgery. Given the nature of the procedure and the lack of complications, this situation is low-stakes within the context of surgical interventions.


Medical Specialty: Pediatrics - Neonatal
Sample Name: Prematurity - Discharge Summary

ADMITTING DIAGNOSES,1. Prematurity.,2. Appropriate for gestational age.,3. Maternal group B streptococcus positive culture.,DISCHARGE DIAGNOSES,1. Prematurity, 34 weeks' gestation, now 5 days old.,2. Group B streptococcus exposure, but no sepsis.,3. Physiologic jaundice.,4. Feeding problem.,HISTORY OF ILLNESS:  ,This is a 4-pound female infant born to a 26-year-old gravida 1, now para 1-0-0-1 lady with an EDC of November 19, 2003.  Group B streptococcus culture was positive on September 29, 2003, and betamethasone was given 1 dose prior to delivery.  Mother also received 1 dose of penicillin approximately 1-1/2 hours prior to delivery.  The infant delivered vaginally, had a double nuchal cord and required CPAP and free flow oxygen.  Her Apgars were 8 at 1 minute and 9 at 5 minutes.  At the end of delivery, it was noted there was a partial placental abruptio.,HOSPITAL COURSE:  ,The infant has had a basically uncomplicated hospital course.  She did not require oxygen.  She did have antibiotics, ampicillin and gentamicin for approximately 48 hours to cover for possible group B streptococcus.  The culture was negative and the antibiotics were stopped at 48 hours.,The infant was noted to have physiologic jaundice and her highest bilirubin was 7.1.  She was treated for approximately 24 hours with phototherapy and the bilirubin on October 15, 2003 was 3.4.,FEEDING: , The infant has had some difficulty with feeding, but at the time of discharge, she is taking approximately 30 mL every feeding and is taking Formula or breast milk, that is, ___ 24 calories per ounce.,PHYSICAL EXAMINATION:, ,VITAL SIGNS:  At discharge, reveals a well-developed infant whose temperature is 98.3, pulse 156, respirations 35, her weight is 1779 g (1% below her birthweight).,HEENT:  Head is normocephalic.  Eyes are without conjunctival injection.  Red reflex is elicited bilaterally.  TMs not well visualized.  Nose and throat are patent without palatal defect.,NECK:  Supple without clavicular fracture.,LUNGS:  Clear to auscultation.,HEART:  Regular rate without murmur, click or gallop present.,EXTREMITIES:  Pulses are 2/4 for brachial and femoral.  Extremities without evidence of hip defects.,ABDOMEN:  Soft, bowel sounds present.  No masses or organomegaly.,GENITALIA:  Normal female, but the clitoris is not covered by the labia majora.,NEUROLOGICAL:  The infant has good Moro, grasp, and suck reflexes.,INSTRUCTIONS FOR CONTINUING CARE,The infant will be discharged home.  She will have home health visits one time per week for 3 weeks, and she will be seen in followup at San Juan Pediatrics the week of October 20, 2003.  She is to continue feeding with either breast milk or Formula, that is, ___ to 24 calories per ounce.,CONDITION: , Her condition at discharge is good.
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DESCRIPTION: Prematurity, 34 weeks' gestation, now 5 days old, group B streptococcus exposure, but no sepsis, physiologic jaundice, and feeding problem.

The case involves a premature infant, which inherently involves higher risks due to their vulnerability. The infant was exposed to group B streptococcus, but fortunately, there was no sepsis. However, the presence of physiologic jaundice and feeding issues requires careful monitoring. While currently the condition at discharge is stable and good, such scenarios can quickly change, thus necessitating continued care and follow-ups. The stakes are moderate to high due to the complications associated with prematurity and the vulnerability of the neonatal patient.


Medical Specialty: General Medicine
Sample Name: Followup on Asthma

SUBJECTIVE: , This is a 42-year-old white female who comes in today for a complete physical and follow up on asthma.  She says her asthma has been worse over the last three months.  She has been using her inhaler daily.  Her allergies seem to be a little bit worse as well.  Her husband has been hauling corn and this seems to aggravate things.  She has not been taking Allegra daily but when she does take it, it seems to help somewhat.  She has not been taking her Flonase which has helped her in the past.  She also notes that in the past she was on Advair but she got some vaginal irritation with that.,She had been noticing increasing symptoms of irritability and PMS around her menstrual cycle.  She has been more impatient around that time.  Says otherwise her mood is normal during the rest of the month.  It usually is worse the week before her cycle and improves the day her menstrual cycle starts.  Menses have been regular but somewhat shorter than in the past.  Occasionally she will get some spotting after her cycles.  She denies any hot flashes or night sweats with this.  In reviewing the chart it is noted that she did have 3+ blood with what appeared to be a urinary tract infection previously.  Her urine has not been rechecked.  She recently had lab work and cholesterol drawn for a life insurance application and is going to send me those results when available.,REVIEW OF SYSTEMS: , As above.  No fevers, no headaches, no shortness of breath currently.  No chest pain or tightness.  No abdominal pain, no heartburn, no constipation, diarrhea or dysuria.  Occasional stress incontinence.  No muscle or joint pain.  No concerns about her skin.  No polyphagia, polydipsia or polyuria.,PAST MEDICAL HISTORY: , Significant for asthma, allergic rhinitis and cervical dysplasia.,SOCIAL HISTORY: , She is married.  She is a nonsmoker.,MEDICATIONS: , Proventil and Allegra.,ALLERGIES: , Sulfa.,OBJECTIVE:,Vital signs:  Her weight is 151 pounds.  Blood pressure is 110/60.  Pulse is 72.  Temperature is 97.1 degrees.  Respirations are 20.,General:  This is a well-developed, well-nourished 42-year-old white female, alert and oriented in no acute distress.  Affect is appropriate and is pleasant.,HEENT:  Normocephalic, atraumatic.  Tympanic membranes are clear.  Conjunctivae are clear.  Pupils are equal, round and reactive to light.  Nares without turbinate edema.  Oropharynx is nonerythematous.,Neck:  Supple without lymphadenopathy, thyromegaly, carotid bruit or JVD.,Chest:  Clear to auscultation bilaterally.,Cardiovascular:  Regular rate and rhythm without murmur.,Abdomen:  Soft, nontender, nondistended.  Normoactive bowel sounds.  No masses or organomegaly to palpation.,Extremities:  Without cyanosis or edema.,Skin:  Without abnormalities.,Breasts:  Normal symmetrical breasts without dimpling or retraction.  No nipple discharge.  No masses or lesions to palpation.  No axillary masses or lymphadenopathy.,Genitourinary:  Normal external genitalia.  The walls of the vaginal vault are visualized with normal pink rugae with no lesions noted.  Cervix is visualized without lesion.  She has a moderate amount of thick white/yellow vaginal discharge in the vaginal vault.  No cervical motion tenderness.  No adnexal tenderness or fullness.,ASSESSMENT/PLAN:,1.  Asthma.  Seems to be worse than in the past.  She is just using her Proventil inhaler but is using it daily.  We will add Flovent 44 mcg two puffs p.o. b.i.d.  May need to increase the dose.  She did get some vaginal irritation with Advair in the past but she is willing to retry that if it is necessary.  May also need to consider Singulair.  She is to call me if she is not improving.  If her shortness of breath worsens she is to call me or go into the emergency department.  We will plan on following up for reevaluation in one month.,2.  Allergic rhinitis.  We will plan on restarting Allegra and Flonase daily for the time being.,3.  Premenstrual dysphoric disorder.  She may have some perimenopausal symptoms.  We will start her on fluoxetine 20 mg one tablet p.o. q.d.,4.  Hematuria.  Likely this is secondary to urinary tract infection but we will repeat a UA to document clearing.  She does have some frequent dysuria but is not having it currently.,5.  Cervical dysplasia.  Pap smear is taken.  We will notify the patient of results.  If normal we will go back to yearly Pap smear.  She is scheduled for screening mammogram and instructed on monthly self-breast exam techniques.  Recommend she get 1200 mg of calcium and 400 U of vitamin D a day.
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DESCRIPTION: A female for a complete physical and follow up on asthma with allergic rhinitis.

The patient has an exacerbation of asthma, but there are no immediate life-threatening symptoms reported such as severe shortness of breath or chest pain. She has a plan for managing her symptoms, and emergency protocols are in place if needed. Other issues like allergic rhinitis, premenstrual symptoms, and a past urinary tract infection are being managed and monitored. Although asthma can be serious, the absence of acute distress during the visit suggests that the immediate stakes are not extremely high.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Diabetes Mellitus Followup

PROBLEM LIST:,1.  Type 1 diabetes mellitus, insulin pump.,2.  Hypertension.,3.  Hyperlipidemia.,HISTORY OF PRESENT ILLNESS: , The patient is a 39-year-old woman returns for followup management of type 1 diabetes mellitus.  Her last visit was approximately 4 months ago.  Since that time, the patient states her health had been good and her glycemic control had been good, however, within the past 2 weeks she had a pump malfunction, had to get a new pump and was not certain of her pump settings and has been having some difficulty with glycemic control over the past 2 weeks.  She is not reporting any severe hypoglycemic events, but is having some difficulty with hyperglycemia both fasting and postprandial.  She is not reporting polyuria, polydipsia or polyphagia.  She is not exercising at this point and has a diet that is rather typical of woman with twins and a young single child as well.  She is working on a full-time basis and so eats on the run a lot, probably eats more than she should and not making the best choices, little time for physical activity.  She is keeping up with all her other appointments and has recently had a good eye examination.  She had lab work done at her previous visit and this revealed persistent hyperlipidemic state with a LDL of 144.,CURRENT MEDICATIONS:,1.  Zoloft 50 mg p.o. once daily.,2.  Lisinopril 40 mg once daily.,3.  Symlin 60 micrograms, not taking at this point.,4.  Folic acid 2 by mouth every day.,5.  NovoLog insulin via insulin pump about 90 units of insulin per day.,REVIEW OF SYSTEMS:,  She denies fever, chills, sweats, nausea, vomiting, diarrhea, constipation, abdominal pain, chest pain, shortness of breath, difficulty breathing, dyspnea on exertion or change in exercise tolerance.  She is not having painful urination or blood in the urine.  She is not reporting polyuria, polydipsia or polyphagia.,PHYSICAL EXAMINATION:,GENERAL:  Today showed a very pleasant, well-nourished woman, in no acute distress.  VITAL SIGNS:  Temperature not taken, pulse 98, respirations 20, blood pressure 148/89, and weight 91.19 kg.  THORAX:  Revealed lungs clear, PA and lateral without adventitious sounds.  CARDIOVASCULAR:  Demonstrated regular rate and rhythm.  S1 and S2 without murmur.  No S3, no S4 auscultated.  ABDOMEN:  Nontender.  EXTREMITIES:  Showed no clubbing, cyanosis or edema.  SKIN:  Intact and do not appear atrophic.  Deep tendon reflexes were 2+/4 without a delayed relaxation phase.,LABORATORY DATA:,  Dated 10/05/08 showed a total cholesterol of 223, triglyceride 140, HDL 54, and LDL 144.  The hemoglobin A1c was 6.4 and the spot urine for microalbumin was 9.2 micrograms of protein, 1 mg of creatinine.  Sodium 136, potassium 4.5, chloride 102, CO2 30 mEq, BUN 11 mg/dL, creatinine 0.6 mg, estimated GFR greater than 60, blood sugar 118, calcium 9.4, and her LFTs were unremarkable.  TSH is 1.07 and free T4 is 0.81.,ASSESSMENT AND PLAN:,1.  This is a return visit to the endocrine clinic for the patient, a 39-year-old woman with history as noted above.  Plan today is to make adjustments to her pump based on a total daily dose of 90 units of insulin.  Basal rate is as follows, 12 a.m. 1.5, 02:30 a.m. 1.75, and 6 a.m. 1.5.  Her correction factor is 19.  Her carb/insulin ratio is 6.  Her active insulin time is 5 and her targets are at 12 a.m. 110 and 6 a.m. to midnight is 100.  We made adjustments to her pump and the plan will be to see her back in approximately 2 months.,2.  Hyperlipidemia.  The patient is not taking statin, therefore, we will prescribe Lipitor 20 mg one p.o. once daily.  Have her watch for side effects from the medication and plan to do a fasting lipid panel and CMP approximately 8 weeks from now.,3.  We will get a hemoglobin A1c and spot urine for albumin in 8 weeks as well.
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DESCRIPTION: Return visit to the endocrine clinic for followup management of type 1 diabetes mellitus.  Plan today is to make adjustments to her pump based on a total daily dose of 90 units of insulin.

soap / chart / progress notes, endocrine clinic, insulin pump, diabetes mellitus, insulin, glycemic, fasting, polyuria, polydipsia, polyphagia, diabetes,

The situation described involves the follow-up management of a patient with Type 1 diabetes mellitus, hypertension, and hyperlipidemia. Type 1 diabetes is a chronic, life-long condition requiring careful management, particularly with regards to insulin pump settings that were recently changed due to malfunction, leading to suboptimal glycemic control. Although the patient is not experiencing severe symptoms or acute complications, proper management and adjustments are crucial to prevent potential long-term complications such as diabetic ketoacidosis or cardiovascular issues due to her other conditions (hypertension and hyperlipidemia). Therefore, the stakes are significant but not immediately life-threatening.


Medical Specialty: General Medicine
Sample Name: Discharge Summary - 13

ADMITTING DIAGNOSES:,1.  Bradycardia.,2.  Dizziness.,3.  Diabetes.,4.  Hypertension.,5.  Abdominal pain.,DISCHARGE DIAGNOSIS:,  Sick sinus syndrome.  The rest of her past medical history remained the same.,PROCEDURES DONE: , Permanent pacemaker placement after temporary internal pacemaker.,HOSPITAL COURSE: , The patient was admitted to the intensive care unit.  Dr. X was consulted.  A temporary intracardiac pacemaker was placed.  Consultation was requested to Dr. Y. He considered the need to have a permanent pacemaker after reviewing electrocardiograms and telemetry readings.  The patient remained in sinus rhythm with severe bradycardias, but all of them one to one transmission.  This was considered to be a sick sinus syndrome.  Permanent pacemaker was placed on 09/05/2007 with right atrium appendage and right ventricular apex electrode placement.  This is a Medtronic pacemaker.  After this, the patient remained with pain in the left side of the chest in the upper area as expected, but well controlled.  Right femoral artery catheter was removed.  The patient remained with good pulses in the right lower extremity with no hematoma.  Other problem was the patient's blood pressure, which on 09/05/2007 was found at 180/90.  Medication was adjusted to benazepril 20 mg a day.  Norvasc 5 mg was added as well.  Her blood pressure has remained better, being today 144/74 and 129/76.,FINAL DIAGNOSES:  ,Sick sinus syndrome.  The rest of her past medical history remained without change, which are:,1.  Diabetes mellitus.,2.  History of peptic ulcer disease.,3.  Hypertension.,4.  Insomnia.,5.  Osteoarthritis.,PLAN: , The patient is discharged home to continue her previous home medications, which are:,1.  Actos 45 mg a day.,2.  Bisacodyl 10 mg p.o. daily p.r.n. constipation.,3.  Cosopt eye drops, 1 drop in each eye 2 times a day.,4.  Famotidine 20 mg 1 tablet p.o. b.i.d.,5.  Lotemax 0.5% eye drops, 1 drop in each eye 4 times a day.,6.  Lotensin (benazepril) increased to 20 mg a day.,7.  Triazolam 0.125 mg p.o. at bedtime.,8.  Milk of Magnesia suspension 30 mL daily for constipation.,9.  Tylenol No.  3, one to two tablets every 6 hours p.r.n. pain.,10.  Promethazine 25 mg IM every 6 hours p.r.n. nausea or vomiting.,11.  Tylenol 325 mg tablets every 4 to 6 hours as needed for pain.,12.  The patient will finish cefazolin 1 g IV every 6 hours, total 5 dosages after pacemaker placement.,DISCHARGE INSTRUCTIONS: , Follow up in the office in 10 days for staple removal.  Resume home activities as tolerated with no starch, sugar-free diet.
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DESCRIPTION: Bradycardia, dizziness, diabetes, hypertension, abdominal pain, and sick sinus syndrome.

The situation involves a discharge summary for a patient following a significant medical intervention, including the placement of a permanent pacemaker due to a condition (sick sinus syndrome) that could be life-threatening if untreated. Additionally, the patient has multiple chronic conditions to manage, such as diabetes and hypertension. The discharge instructions include multiple medications and a follow-up plan, indicating ongoing medical management is critical. However, given that this is a discharge summary indicating that the critical procedure was successful and the patient is in stable condition, the immediacy of high risk is reduced. This makes it a moderately high-stakes situation due to the complexity and the potential impact on the patient's ongoing health management.


Medical Specialty: Orthopedic
Sample Name: MRI Knee - 2

EXAM:,MRI LEFT KNEE WITHOUT CONTRAST,CLINICAL:,This is a 53-year-old female with left knee pain being evaluated for ACL tear.,FINDINGS:,This examination was performed on 10-14-05.,Normal medial meniscus without intrasubstance degeneration, surface fraying or discrete meniscal tear.,There is a discoid lateral meniscus and although there may be minimal superficial fraying along the inner edge of the body, there is no discrete tear (series #6 images #7-12).,There is a near-complete or complete tear of the femoral attachment of the anterior cruciate ligament. The ligament has a balled-up appearance consistent with at least partial retraction of most of the fibers of the ligament. There may be a few fibers still intact (series #4 images #12-14; series #5 images #12-14). The tibial fibers are normal.,Normal posterior cruciate ligament.,There is a sprain of the medial collateral ligament, with mild separation of the deep and superficial fibers at the femoral attachment (series #7 images #6-12). There is no complete tear or discontinuity and there is no meniscocapsular separation.,There is a sprain of the lateral ligament complex without focal tear or discontinuity of any of the intraarticular components.,Normal iliotibial band.,Normal quadriceps and patellar tendons.,There is contusion within the posterolateral corner of the tibia. There is also contusion within the patella at the midline patellar ridge where there is an area of focal chondral flattening (series #8 images #10-13). The medial and lateral patellar facets are otherwise normal as is the femoral trochlea in the there is no patellar subluxation.,There is a mild strain of the vastus medialis oblique muscle extending into the medial patellofemoral ligament and medial patellar retinaculum but there is no complete tear or discontinuity.,Normal lateral patellar retinaculum. There is a joint effusion and plica.,IMPRESSION:, Discoid lateral meniscus without a tear although there may be minimal superficial fraying along the inner edge of the body.  Near-complete if not complete tear of the femoral attachment of the anterior cruciate ligament.  Medial capsule sprain with associated strain of the vastus medialis oblique muscle.  There is focal contusion within the patella at the midline patella ridge. Joint effusion and plica.
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DESCRIPTION: A 53-year-old female with left knee pain being evaluated for ACL tear.

orthopedic, vastus medialis oblique muscle, medialis oblique, oblique muscle, patellar retinaculum, joint effusion, femoral attachment, cruciate ligament, complete tear, meniscus, superficial, cruciate, sprain, femoral, medial, ligament, tear, patellar

The situation described involves a detailed MRI report for a 53-year-old female patient being evaluated for a potential ACL tear. The findings indicate a near-complete or complete tear of the ACL, a critical ligament in the knee, which is a significant orthopedic issue because it can severely impact the patient's mobility and quality of life. Given the potential need for surgical intervention and the implications for the patient's future physical activity, this is a moderately high-stakes situation in the context of orthopedic medical practice.


Medical Specialty: Surgery
Sample Name: CABG - 1

PREOPERATIVE DIAGNOSIS: , Coronary occlusive disease.,POSTOPERATIVE DIAGNOSIS: , Coronary occlusive disease.,OPERATION PROCEDURE: , Coronary bypass graft x2 utilizing left internal mammary artery, the left anterior descending, reverse autogenous reverse autogenous saphenous vein graft to the obtuse marginal.  Total cardiopulmonary bypass, cold-blood potassium cardioplegia, antegrade for myocardial protection.,INDICATION FOR THE PROCEDURE:  ,The patient was a 71-year-old female transferred from an outside facility with the left main, proximal left anterior descending, and proximal circumflex severe coronary occlusive disease, ejection fraction about 40%.,FINDINGS: , The LAD was 2-mm vessel and good, mammary was good, and obtuse marginal was 2-mm vessel and good, and the main was good.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room and placed in the supine position.  Adequate general endotracheal anesthesia was induced.  Appropriate monitoring devices were placed.  The chest, abdomen and legs were prepped and draped in the sterile fashion.  The right greater saphenous vein was harvested and prepared by 2 interrupted skin incisions and by ligating all branches with 4-0 Surgilon and flushed with heparinized blood.  Hemostasis was achieved in the legs and closed with running 2-0 Dexon in the subcutaneous tissue and running 3-0 Dexon subcuticular in the skin.,Median sternotomy incision was made and the left mammary artery was dissected free from its takeoff of the subclavian to its bifurcation at the diaphragm and surrounded with papaverine-soaked gauze.  The pericardium was opened.  The pericardial cradle was created.  The patient was fully heparinized and cannulated with a single aortic and single venous cannula and bypass was instituted.  A retrograde cardioplegic cannula was placed with a pursestring suture of 4-0 Prolene suture in the right atrial wall into the coronary sinus and tied to a Rumel tourniquet.  An antegrade cardioplegic needle sump combination was placed in the ascending aorta and tied in place with 4-0 Prolene.  Cardiopulmonary bypass was instituted and the ascending aorta was crossclamped.  Antegrade cardioplegia was given at a total of 5 mL per kg through the aortic route.  This was followed by something in the aortic route and retrograde cardioplegia through the coronary sinus at a total of 5 mL per kg.  The obtuse marginal coronary was identified and opened.,End-to-side anastomosis was performed with a running 7-0 Prolene suture and the vein was cut to length.  Cold antegrade and retrograde potassium cardioplegia were given.  The mammary artery was clipped distally, divided and spatulated for anastomosis.  The anterior descending was identified and opened.  End-to-side anastomosis was performed with running 8-0 Prolene suture and the warm blood potassium cardioplegia was given antegrade and retrograde and the aortic cross-clamp was removed.  The partial occlusion clamp was placed.  Aortotomies were made.  The veins were cut to fit these and sutured in place with running 5-0 Prolene suture.  A partial occlusion clamp was removed.  All anastomoses were inspected and noted to be patent and dry.  Ventilation was commenced.  The patient was fully warm and the patient was then wean from cardiopulmonary bypass.  The patient was decannulated in routine fashion.  Protamine was given.  Good hemostasis was noted.  A single mediastinal chest tube and bilateral pleural Blake drains were placed.  The sternum was closed with figure-of-eight stainless steel wire plus two 5-mm Mersiline tapes.,The linea alba was closed with figure-of-eight of #1 Vicryl, the sternal fascia closed with running #1 Vicryl, the subcu closed with running 2-0 Dexon, skin with running 4-0 Dexon subcuticular stitch.  The patient tolerated the procedure well.
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DESCRIPTION: Coronary bypass graft x2 utilizing left internal mammary artery, the left anterior descending, reverse autogenous reverse autogenous saphenous vein graft to the obtuse marginal.  Total cardiopulmonary bypass, cold-blood potassium cardioplegia, antegrade for myocardial protection.

surgery, coronary occlusive disease, coronary bypass graft, cabg, myocardial, mammary artery, obtuse marginal, cardiopulmonary bypass, potassium cardioplegia, prolene suture, bypass, artery, anastomosis, autogenous, obtuse, marginal, cardiopulmonary, potassium, retrograde, cardioplegia, antegrade, coronary

A Coronary Artery Bypass Graft (CABG) is a major surgical procedure performed on patients with coronary occlusive disease to improve blood flow to the heart. The stakes are high because it involves stopping the heart and using cardiopulmonary bypass, which carries risks of complications such as bleeding, infection, or heart attack. The patient's advanced age and reduced ejection fraction increase the procedural risks. Successful execution can significantly impact the patient's quality of life and survival.


Medical Specialty: Urology
Sample Name: Neuromodulator

PREOPERATIVE DIAGNOSIS:,  Refractory urgency and frequency.,POSTOPERATIVE DIAGNOSIS: , Refractory urgency and frequency.,OPERATION: , Stage I and II neuromodulator.,ANESTHESIA: , Local MAC.,ESTIMATED BLOOD LOSS:,  Minimal.,FLUIDS: , Crystalloid.  The patient was given Ancef preop antibiotic.  Ancef irrigation was used throughout the procedure.,BRIEF HISTORY: , The patient is a 63-year-old female who presented to us with urgency and frequency on physical exam.  There was no evidence of cystocele or rectocele.  On urodyanamcis, the patient has significant overactivity of the bladder.  The patient was tried on over three to four different anticholinergic agents such as Detrol, Ditropan, Sanctura, and VESIcare for at least one month each.  The patient had pretty much failure from each of the procedure.  The patient had less than 20% improvement with anticholinergics.  Options such as continuously trying anticholinergics, continuation of the Kegel exercises, and trial of InterStim were discussed.  The patient was interested in the trial.  The patient had percutaneous InterStim trial in the office with over 70% to 80% improvement in her urgency, frequency, and urge incontinence.  The patient was significantly satisfied with the results and wanted to proceed with stage I and II neuromodulator.  Risks of anesthesia, bleeding, infection, pain, MI, DVT, and PE were discussed.  Risk of failure of the procedure in the future was discussed.,Risk of lead migration that the treatment may or may not work in the long-term basis and data on the long term were not clear were discussed with the patient.  The patient understood and wanted to proceed with stage I and II neuromodulator.  Consent was obtained.,DETAILS OF THE OPERATION: , The patient was brought to the OR.  The patient was placed in prone position.  A pillow was placed underneath her pelvis area to slightly lift the pelvis up.  The patient was awake, was given some MAC anesthesia through the IV, but the patient was talking and understanding and was able to verbalize issues.  The patient's back was prepped and draped in the usual sterile fashion.  Lidocaine 1% was applied on the right side near the S3 foramen.  Under fluoroscopy, the needle placement was confirmed.  The patient felt stimulation in the vaginal area, which was tapping in nature.  The patient also had a pressure feeling in the vaginal area.  The patient had no back sensation or superficial sensation.  There was no sensation down the leg.  The patient did have __________, which turned in slide bellows response indicating the proper positioning of the needle.  A wire was placed.  The tract was dilated and lead was placed.  The patient felt tapping in the vaginal area, which is an indication that the lead is in its proper position.  Most of the leads had very low amplitude and stimulation.  Lead was tunneled under the skin and was brought out through an incision on the left upper buttocks.  Please note that the lidocaine was injected prior to the tunneling.  A pouch was created about 1 cm beneath the subcutaneous tissue over the muscle where the actual unit was connected to the lead.  Screws were turned and they were dropped.  Attention was made to ensure that the lead was all the way in into the InterStim.  Irrigation was performed after placing the main unit in the pouch.  Impedance was checked.  Irrigation was again performed with antibiotic irrigation solution.  The needle site was closed using 4-0 Monocryl.  The pouch was closed using 4-0 Vicryl and the subcutaneous tissue with 4-0 Monocryl.  Dermabond was applied.,The patient was brought to recovery in a stable condition.
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DESCRIPTION: Stage I and II neuromodulator.

Stage I and II neuromodulator.

urology, refractory urgency, urgency, frequency, neuromodulator, subcutaneous tissue, interstim,

The situation involves a surgical procedure to address a condition that has not responded well to other treatments. While the procedure itself is not as high-risk as major surgeries, it still involves risks common to surgeries such as infection, bleeding, and anesthesia-related complications. The condition being treated significantly affects the patient's quality of life, and the surgery is expected to bring substantial improvement. Nonetheless, the stakes are not life-threatening, and the patient remained stable post-operation.


Medical Specialty: Surgery
Sample Name: Mohs Micrographic Surgery - 1

PREOP DIAGNOSIS: , Basal Cell CA.,POSTOP DIAGNOSIS:,  Basal Cell CA.,LOCATION: , Mid parietal scalp.,PREOP SIZE:,  1.5 x 2.9 cm,POSTOP SIZE:,  2.7 x 2.9 cm,INDICATION:,  Poorly defined borders.,COMPLICATIONS:,  None.,HEMOSTASIS:, Electrodessication.,PLANNED RECONSTRUCTION:,  Simple Linear Closure.,DESCRIPTION OF PROCEDURE:,  Prior to each surgical stage, the surgical site was tested for anesthesia and reanesthetized as needed, after which it was prepped and draped in a sterile fashion.,The clinically-apparent tumor was carefully defined and debulked prior to the first stage, determining the extent of the surgical excision.  With each stage, a thin layer of tumor-laden tissue was excised with a narrow margin of normal appearing skin, using the Mohs fresh tissue technique.  A map was prepared to correspond to the area of skin from which it was excised.  The tissue was prepared for the cryostat and sectioned.  Each section was coded, cut and stained for microscopic examination.  The entire base and margins of the excised piece of tissue were examined by the surgeon.  Areas noted to be positive on the previous stage (if applicable) were removed with the Mohs technique and processed for analysis.,No tumor was identified after the final stage of microscopically controlled surgery.  The patient tolerated the procedure well without any complication.  After discussion with the patient regarding the various options, the best closure option for each defect was selected for optimal functional and cosmetic results.
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DESCRIPTION: Mohs Micrographic Surgery for basal cell CA at mid parietal scalp.

surgery, basal cell ca, basal cell, mohs technique, mohs, tumor-laden tissue, mohs fresh tissue technique, mohs micrographic surgery, micrographic surgery, parietal scalp, micrographic, basal, cell, ca, surgical, tumor, tissue, stage,

Mohs micrographic surgery is a common procedure used to treat basal cell carcinoma, which is a type of skin cancer. While dealing with cancer always carries some level of significance, the procedure itself is well-established and commonly performed, typically in an outpatient setting. The document indicates no complications and successful removal of the tumor, suggesting the outcome is positive. The stakes here are moderate given it's cancer treatment, but since it's a procedure with a high success rate for a non-life-threatening condition if treated promptly, it doesn't reach the highest levels of stakes.


Medical Specialty: Surgery
Sample Name: Ttriple-Lumen Central Line

PREOPERATIVE DIAGNOSES,1.  Bowel obstruction.,2.  Central line fell off.,POSTOPERATIVE DIAGNOSES,1.  Bowel obstruction.,2.  Central line fell off.,PROCEDURE: , Insertion of a triple-lumen central line through the right subclavian vein by the percutaneous technique.,PROCEDURE DETAIL: , This lady has a bowel obstruction.  She was being fed through a central line, which as per the patient was just put yesterday and this slipped out.  At the patient's bedside after obtaining an informed consent, the patient's right deltopectoral area was prepped and draped in the usual fashion.  Xylocaine 1% was infiltrated and with the patient in Trendelenburg position, she had her right subclavian vein percutaneously cannulated without any difficulty.  A Seldinger technique was used and a triple-lumen catheter was inserted.  There was a good flow through all three ports, which were irrigated with saline prior to connection to the IV solutions.,The catheter was affixed to the skin with sutures and then a dressing was applied.,The postprocedure chest x-ray revealed that there were no complications to the procedure and that the catheter was in good place.
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DESCRIPTION: Insertion of a triple-lumen central line through the right subclavian vein by the percutaneous technique.  This lady has a bowel obstruction.  She was being fed through a central line, which as per the patient was just put yesterday and this slipped out.

surgery, central line, triple lumen central line, subclavian vein, bowel obstruction, lumen, percutaneous, bowel, obstruction

The situation involves a patient with a bowel obstruction, which is a serious condition that may lead to further complications if not managed properly. Additionally, the incident of the central line falling off is significant because central lines are crucial for delivering nutrition and medication in such cases. The re-insertion of a central line is a routine but critical procedure, as it carries risks such as infection, pneumothorax, or improper placement. While the technical aspect of the procedure seems to have been executed without complications, the overall clinical scenario presents inherently high stakes due to the critical nature of central line placement in a patient with a bowel obstruction.


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

Medical Specialty: Obstetrics / Gynecology
Sample Name: Vacuum D&C

PREOPERATIVE DIAGNOSIS: , Blighted ovum, severe cramping.,POSTOPERATIVE DIAGNOSIS:,  Blighted ovum, severe cramping.,OPERATION PERFORMED: , Vacuum D&C.,DRAINS: , None.,ANESTHESIA: , General.,HISTORY: , This 21-year-old white female gravida 1, para 0 who was having severe cramping and was noted to have a blighted ovum with her first ultrasound in the office.  Due to the severe cramping, a decision to undergo vacuum D&C was made.  At the time of the procedure, moderate amount of tissue was obtained.,PROCEDURE:  ,The patient was taken to the operating room and placed in a supine position, at which time a general form of anesthesia was administered by the anesthesia department.  The patient was then repositioned in a modified dorsal lithotomy position and then prepped and draped in the usual fashion.  A weighted vaginal speculum was placed in the posterior vaginal vault.  Anterior lip of the cervix was grasped with single tooth tenaculum, and the cervix was dilated to approximately 8 mm straight.  Plastic curette was placed into the uterine cavity and suction was applied at 60 mmHg to remove the tissue.  This was followed by gentle curetting of the lining as well as followed by suction curetting and then another gentle curetting and a final suction.  Methargen 0.2 mg was given IM and Pitocin 40 units and a 1000 was also started at the time of the procedure.  Once the procedure was completed, the single tooth tenaculum was removed from the vaginal vault with some _____ remaining blood and the weighted speculum was also removed.  The patient was repositioned to supine position and taken to recovery room in stable condition.
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DESCRIPTION: A 21-year-old female was having severe cramping and was noted to have a blighted ovum with her first ultrasound in the office.

obstetrics / gynecology, pitocin, single tooth tenaculum, vaginal vault, vacuum d&c, blighted ovum, speculum, tenaculum, curetting, blighted, cramping,

The situation involves a diagnostic and therapeutic procedure for a young female with a blighted ovum, characterized by severe cramping. A vacuum D&C procedure was performed under general anesthesia, indicating a controlled medical environment. While it is a significant medical procedure for the patient, it is a common procedure in gynecology with a low risk of complications. The stakes involve the patient's physical and emotional well-being, but it is not a life-threatening situation nor a complex surgery. It requires careful medical attention but is not an emergency or high-risk scenario.


Medical Specialty: Gastroenterology
Sample Name: Colonoscopy - 11

MEDICATIONS:,1.  Versed intravenously.,2.  Demerol intravenously.,DESCRIPTION OF THE PROCEDURE: , After informed consent was obtained, the patient was placed in the left lateral decubitus position and sedated with the above medications.  The Olympus video colonoscope was inserted through the anus and was advanced in retrograde fashion through the sigmoid colon, descending colon, around the splenic flexure, into the transverse colon, around the hepatic flexure, down the ascending colon, into the cecum.  The cecum was identified by the presence of the appendiceal orifice and the ileocecal valve.  The colonoscope was then advanced through the ileocecal valve into the terminal ileum, which was normal on examination.  The scope was then pulled back into the cecum and then slowly withdrawn.  The mucosa was examined in detail.  The mucosa was entirely normal.  Upon reaching the rectum, retroflex examination of the rectum was normal.  The scope was then straightened out, the air removed and the scope withdrawn.  The patient tolerated the procedure well.  There were no apparent complications.,
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DESCRIPTION: Colonoscopy.  The Olympus video colonoscope was inserted through the anus and was advanced in retrograde fashion through the sigmoid colon, descending colon, around the splenic flexure, into the transverse colon, around the hepatic flexure, down the ascending colon, into the cecum.

gastroenterology, olympus, scope, sigmoid colon, descending colon, splenic flexure, transverse colon, hepatic flexure, ascending colon, ileocecal valve, ileocecal, mucosa, rectum, colonoscope, flexure, cecum, colonoscopyNOTE

The procedure described is a routine colonoscopy, which is a standard diagnostic tool used in gastroenterology. While it involves sedation and the potential for rare complications, such as perforation or bleeding, it is a well-established and common procedure with a low risk profile when performed by experienced practitioners. This specific case describes a normal colonoscopy with no complications, and the patient tolerated the procedure well. Therefore, the stakes are not particularly high in this context.


Medical Specialty: Consult - History and Phy.
Sample Name: Cardiac Consultation - 5

REASON FOR REFERRAL: , Cardiac evaluation and treatment in a patient who came in the hospital with abdominal pain.,HISTORY:,  This is a 77-year-old white female patient whom I have known for the last about a year or so who has underlying multiple medical problems including hypertension, hyperlipidemia, diabetes mellitus, coronary artery disease status post aortocoronary bypass surgery about eight years ago at Halifax Medical Center where she had triple vessel bypass surgery with left internal mammary artery to the left anterior descending artery, saphenous vein graft to the left circumflex and right coronary arteries.  Since then, she has generally done well.  She used to be seeing another cardiologist and apparently she had a stress test in September 2008 and she was otherwise cardiac catheterization and coronary angiography, but the patient declined to have one done and since then she has been on medical therapy.,The patient had been on medical therapy at home and generally doing well.  Recently, she had no leg swelling, undue exertional dyspnea, orthopnea, or paroxysmal nocturnal dyspnea.  She denies any rest or exertional chest discomfort.  Yesterday evening, she had her dinner and she was sitting around and she felt discomfort in the chest at about 7:00 p.m.  The discomfort was a crampy pain in the left lower quadrant area, which seemed to radiating to the center of the abdomen and to the right side and it was off and on lasting for a few minutes at a time and then subsiding.  Later on she was nauseous, but she did not have any vomiting.  She denied any diarrhea.  No history of fever or chills.  Since the pain seemed to persist, the patient came to the hospital emergency room at 11:35 p.m. where she was seen and admitted for the same.  She was given morphine, Zofran, Demerol, another Zofran, and Reglan as well as Demerol again and she was given intravenous fluids.  Subsequently, her pain finally went away and she does not have any pain since about 7:00 a.m. this morning.  The patient was admitted however for further workup and treatment.  At the time of my examination this afternoon, the patient is sitting, lying in bed and comfortable and has no abdominal pain of any kind.  She has not been fed any food, however.  The patient also had had pelvis and abdominal CT scan performed, which has been described to be partial small bowel obstruction, internal hernia, volvulus or adhesion most likely in the left flank area.  The patient has had left nephrectomy and splenectomy, which has been described.  A 1.5-mm solid mass is described to be in the lower pole of the kidney.  The patient also has been described to have diverticulosis without diverticulitis on this finding.,Currently however, the patient has no clinical symptoms according to her.,PAST MEDICAL HISTORY:,  She has had hypertension and hyperlipidemia for the last 15 years, diabetes mellitus for the last eight years, and coronary artery disease for last about eight years or so.  She had a chest and back pain about eight years ago for about two weeks and then subsequently she was reported to be evaluated.  She has a small myocardial infarction and then she was under the care of Dr. A and she had aortocoronary bypass surgery at Halifax Medical Center by Dr. B, which was a three-vessel bypass surgery with left internal mammary artery to the left descending artery and saphenous vein graft to the left circumflex and distal right coronary artery respectively.,She had had nuclear stress test with Dr. C on September 3, 2008, which was described to be abnormal with ischemic defects, but I do not think the patient had any further cardiac catheterization and coronary angiography after that.  She has been treated medically.,This patient also had an admission to this hospital in May 2008 also for partial small bowel obstruction and cholelithiasis and sigmoid diverticulosis.  She was described to have had a hemorrhagic cyst of the right kidney.  She has mild arthritis for the last 10 or 15 years.  She has a history of GERD for the last 20 years, and she also has a history of peptic ulcer disease in the duodenum, but never had any bleeding.  She has a history of diverticulosis as mentioned.  No history of TIA or CVA.  She has one kidney.  She was in a car accident in 1978 and afterwards she had to have left nephrectomy as well as splenectomy because of rupture.  The patient has a history of pulmonary embolism once about eight years ago after her aortocoronary bypass surgery.  She describes this to be a clot on left lung.  I am not sure if she had any long-term treatment, however.,In the past, the patient had aortocoronary bypass surgery in 2003 and incisional hernia surgery in 1979 as well as hysterectomy in 1979 and she had splenectomy and nephrectomy as described in 1978.,FAMILY HISTORY: , Her father died at age of 65 of massive heart attack and mother died at age of 62 of cancer.  She had a one brother who died of massive heart attack in his 50s, a brother died at the age of 47 of cancer, and another brother died in his 60s of possible rupture of appendix.,SOCIAL HISTORY: , The patient is a widow.  She lives alone.  She does have three daughters, two of them live in Georgia and one lives in Tennessee.  She did smoke in the past up to one to one and a half packs of cigarettes per day for about 10 years, but she quit long time ago.  She never drank any alcohol.  She likes to drink one or two cups of tea in a day.,ALLERGIES: , PAXIL.,MEDICATIONS:,  Her home medications prior to coming in include some of the following medications, although the exact list is not available in the chart at this stage, but they have been on glyburide, Januvia, lisinopril, metformin, metoprolol, simvastatin, ranitidine, meloxicam, and furosemide.,REVIEW OF SYSTEMS:,  Appetite is good.  She sleeps good at night.  She has no headaches and she has mild joint pains from arthritis.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Pulse 90 per minute and regular, blood pressure 140/90 mmHg, respirations 18, and temperature of 98.5 degree Fahrenheit.  Moderate obesity is present.,CARDIAC:  Carotid upstroke is slightly diminished, but no clear bruit heard.,LUNGS:  Slightly decreased air entry at both bases.  No rales or rhonchi heard.,CARDIOVASCULAR:  PMI in the left fifth intercostal space in the midclavicular line.  Regular heart rhythm.  S1 and S2 normal.  S4 is present.  No S3 heard.  Short ejection systolic murmur grade I/VI is present at the left lower sternal border of the apex, peaking in LV systole, no diastolic murmur heard.,ABDOMEN:  Soft, obese, no tenderness, no masses felt.  Bowel sounds are present.,EXTREMITIES:  Bilateral trace edema.  The extremities are heavy.  There is no pitting at this stage.  No clubbing or cyanosis.  Distal pulses are fair.,CENTRAL NERVOUS SYSTEM:  Without any obvious focal deficits.,LABORATORY DATA: , Includes an electrocardiogram, which shows normal sinus rhythm, left atrial enlargement, and right bundle branch block.  This is overall unchanged compared to previous electrocardiogram, which also has the same present.  Nuclear stress test from 2008 was described to show ejection fraction of 49% and inferior and posterolateral ischemia.  Otherwise, laboratory data includes on this patient at this stage WBC 18.3, hemoglobin 15.5, hematocrit is 47.1, and platelet count is 326,000.  Electrolytes, sodium 137, potassium 5.2, chloride 101, CO2 27, BUN 34, creatinine 1.2, calcium 9.5, and magnesium 1.7.  AST and ALT are normal.  Albumin is 4.1.  Lipase and amylase are normal.  INR is 0.92.  Urinalysis is relatively unremarkable except for trace protein.  Chest x-ray has been described to show elevated left hemidiaphragm and median sternotomy sutures.  No infiltrates seen.  Abdomen and pelvis CAT scan findings are as described before with suggestion of partial small bowel obstruction and internal hernia.  Volvulus or adhesions have been considered.  Left nephrectomy and splenectomy demonstrated right kidney has a 1.5 cm solid mass at the lower pole suspicious for neoplasm according to the radiologist's description and there is diverticulosis.,IMPRESSION:,1.  Coronary artery disease and prior aortocoronary bypass surgery, currently clinically the patient without any angina.,2.  Possible small old myocardial infarction.,3.  Hypertension with hypertensive cardiovascular disease.,4.  Non-insulin-dependent diabetes mellitus.,5.  Moderate obesity.,6.  Hyperlipidemia.,7.  Chronic non-pitting leg edema.,8.  Arthritis.,9.  GERD and positive history of peptic ulcer disease.,CONCLUSION:,1.  Past left nephrectomy and splenectomy after an accident and injury and rupture of the spleen.,2.  Abnormal nuclear stress test in September 2008, but no further cardiac studies performed, such as cardiac catheterization.,3.  Lower left quadrant pain, which could be due to diverticulosis.,4.  Diverticulosis and partial bowel obstruction.,RECOMMENDATION:,1.  At this stage, the patient's cardiac medication should be continued if the patient is allowed p.o. intake.
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DESCRIPTION: Cardiac evaluation and treatment in a patient who came in the hospital with abdominal pain.

The situation involves a 77-year-old patient with a complex medical history, including prior coronary artery disease and bypass surgery, diabetes, hypertension, and possible partial bowel obstruction. She was admitted to the hospital after experiencing chest and abdominal pain. Given the patient's advanced age, history of heart disease, recent chest discomfort, and the potential for serious abdominal issues like volvulus, her condition requires careful monitoring and treatment. However, the current clinical impression suggests she is stable and without significant cardiac symptoms, thus the immediate risk is somewhat controlled. Nevertheless, the combination of potential cardiovascular and gastrointestinal complications together with her complex medical history elevates the stakes of the situation.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Holter Monitoring

INDICATION: , Bradycardia and dizziness.,COMMENTS:,1.  The patient was monitored for 24 hours.,2.  The predominant rhythm was normal sinus rhythm with a minimum heart rate of 56 beats per minute and the maximum heart rate of 114 beats per minute and a mean heart rate of 86 beats per minute.,3.  There were occasional premature atrial contractions seen, no supraventricular tachycardia was seen.,4.  There was a frequent premature ventricular contraction seen.  Between 11:00 a.m. and 11:15 a.m. the patient was in ventricular bigemini and trigemini most of the time.  During rest of the monitoring period, there were just occasional premature ventricular contractions seen.  No ventricular tachycardia was seen.,5.  There were no pathological pauses noted.,6.  The longest RR interval was 1.1 second.,7.  There were no symptoms reported.
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DESCRIPTION: Holter monitoring - For bradycardia and dizziness.

cardiovascular / pulmonary, holter monitoring, bradycardia, bigemini, dizziness, heart rate, interval, predominant, premature, premature ventricular contraction, rhythm, sinus, trigemini, ventricular, bradycardia and dizziness, premature ventricular, monitoring,

The situation involves a cardiovascular assessment of a patient using Holter monitoring, primarily for bradycardia and dizziness. While there are some abnormal findings such as frequent premature ventricular contractions and ventricular bigemini, no severe arrhythmias like ventricular tachycardia were detected, and the patient didn't report symptoms. The findings are notable but not indicating an immediate life-threatening situation as there were no alarming symptoms or critical arrhythmias. However, the presence of frequent PVCs could warrant further monitoring or intervention in the future depending on the patient's overall condition.


Medical Specialty: Radiology
Sample Name: MRI Head

EXAM:,  MRI Head W&WO Contrast.,REASON FOR EXAM:,  Dyspnea.,COMPARISON:,  None. ,TECHNIQUE:,  MRI of the head performed without and with 12 ml of IV gadolinium (Magnevist).  ,INTERPRETATION: , There are no abnormal/unexpected foci of contrast enhancement.  There are no diffusion weighted signal abnormalities.  There are minimal, predominantly periventricular, deep white matter patchy foci of FLAIR/T2 signal hyperintensity, the rest of the brain parenchyma appearing unremarkable in signal.  The ventricles and sulci are prominent, but proportionate.  Per T2 weighted sequence, there is no hyperdense vascularity.  There are no calvarial signal abnormalities.  There is no significant mastoid air cell fluid.  No significant sinus mucosal disease per MRI.,IMPRESSION:,1.  No abnormal/unexpected foci of contrast enhancement; specifically, no evidence for metastases or masses.  ,2.  No evidence for acute infarction. ,3.  Mild, scattered, patchy, chronic small vessel ischemic disease changes. ,4.  Diffuse cortical volume loss, consistent with patient's age. ,5.  Preliminary report was issued at the time of dictation.  ,
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DESCRIPTION: MRI Head W&WO Contrast.

MRI Head W&WO Contrast.

radiology, dyspnea, mri of the head, foci of contrast, patchy foci, white matter, w&wo contrast, mri head, mri

The MRI report for the head does not indicate any immediate or severe findings such as tumors, acute infarctions, or other critical pathologies. The findings described, like chronic small vessel ischemic disease and cortical volume loss, are common in aging populations and typically do not require urgent intervention. Therefore, while the examination is important for understanding the patient's neurological health, it does not present a high-stakes situation that demands immediate action.


Medical Specialty: General Medicine
Sample Name: Gen Med Consult - 27

CHIEF COMPLAINT: , Nausea, vomiting, diarrhea, and fever.,HISTORY OF PRESENT ILLNESS: , This patient is a 76-year-old woman who was treated with intravenous ceftriaxone and intravenous clindamycin at a care facility for pneumonia.  She has developed worsening confusion, fever, and intractable diarrhea.  She was brought to the emergency department for evaluation.  Diagnostic studies in the emergency department included a CBC, which revealed a white blood cell count of 23,500, and a low potassium level of 2.6.  She was admitted to the hospital for treatment of profound hypokalemia, dehydration, intractable diarrhea, and febrile illness.,PAST MEDICAL HISTORY: , Recent history of pneumonia, urosepsis, dementia, amputation, osteoporosis, and hypothyroidism.,MEDICATIONS:  ,Synthroid, clindamycin, ceftriaxone, Remeron, Actonel, Zanaflex, and hydrocodone.,SOCIAL HISTORY: , The patient has been residing at South Valley Care Center.,REVIEW OF SYSTEMS: , The patient is unable answer review of systems.,PHYSICAL EXAMINATION:,GENERAL:  This is a very elderly, cachectic woman lying in bed in no acute distress.,HEENT:  Examination is normocephalic and atraumatic.  The pupils are equal, round and reactive to light and accommodation.  The extraocular movements are full.,NECK:  Supple with full range of motion and no masses.,LUNGS:  There are decreased breath sounds at the bases bilaterally.,CARDIOVASCULAR:  Regular rate and rhythm with normal S1 and S2, and no S3 or S4.,ABDOMEN:  Soft and nontender with no hepatosplenomegaly.,EXTREMITIES:  No clubbing, cyanosis or edema.,NEUROLOGIC:  The patient moves all extremities but does not communicate.,DIAGNOSTIC STUDIES: , The CBC shows a white blood cell count of 23,500, hemoglobin 13.0, hematocrit 36.3, and platelets 287,000.  The basic chemistry panel is remarkable for potassium 2.6, calcium 7.5, and albumin 2.3.,IMPRESSION/PLAN:,1.  Elevated white count.  This patient is admitted to the hospital for treatment of a febrile illness.  There is concern that she has a progression of pneumonia.  She may have aspirated.  She has been treated with ceftriaxone and clindamycin.  I will follow her oxygen saturation and chest x-ray closely.  She is allergic to penicillin.  Therefore, clindamycin is the appropriate antibiotic for possible aspiration.,2.  Intractable diarrhea.  The patient has been experiencing intractable diarrhea.  I am concerned about Clostridium difficile infection with possible pseudomembranous colitis.  I will send her stool for Clostridium difficile toxin assay.  I will consider treating with metronidazole.,3.  Hypokalemia.  The patient's profound hypokalemia is likely secondary to her diarrhea.  I will treat her with supplemental potassium.,4.  DNR status:  I have ad a discussion with the patient's daughter, who requests the patient not receive CPR or intubation if her clinical condition or of the patient does not respond to the above therapy.  ,
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DESCRIPTION: Nausea, vomiting, diarrhea, and fever.

Nausea, vomiting, diarrhea, and fever.

The case involves a 76-year-old woman with a complex medical history, including pneumonia, dementia, and recent aggressive antibiotic treatment. She is presenting with a high white blood cell count, severe hypokalemia, intractable diarrhea, and fever. There's a suspicion of a Clostridium difficile infection, which if left untreated, can lead to severe complications. Her condition requires immediate attention and hospitalization. The patient is also in DNR status, making the situation critical as her condition may rapidly deteriorate without intervention. This combination of factors makes the stakes high, particularly because of the potential for serious complications such as cardiac issues from hypokalemia or toxic megacolon from C. difficile.


Medical Specialty: Consult - History and Phy.
Sample Name: Spinal fluid evaluation

HISTORY:  ,This 15-day-old female presents to Children's Hospital and transferred from Hospital Emergency Department for further evaluation.  Information is obtained in discussion with the mother and the grandmother in review of previous medical records.  This patient had the onset on the day of presentation of a jelly-like red-brown stool started on Tuesday morning.  Then, the patient was noted to vomit after feeds.  The patient was evaluated at Hospital with further evaluation with laboratory data showing a white blood cell count elevated at 22.2; hemoglobin 14.1; sodium 138; potassium 7.2, possibly hemolyzed; chloride 107; CO2 23; BUN 17; creatinine 1.2; and glucose of 50, which was repeated and found to be stable in that range.  The patient underwent a barium enema, which was read by the radiologist as negative.  The patient was transferred to Children's Hospital for further evaluation after being given doses of ampicillin, cefotaxime, and Rocephin.,PAST MEDICAL HISTORY: , Further, the patient was born in Hospital.  Birth weight was 6 pounds 4 ounces.  There was maternal hypertension.  Mother denies group B strep or herpes.  Otherwise, no past medical history.,IMMUNIZATIONS: , None today.,MEDICATIONS: , Thrush medicine identified as nystatin.,ALLERGIES: , Denied.,PAST SURGICAL HISTORY: , Denied.,SOCIAL HISTORY:  ,Here with mother and grandmother, lives at home.  There is no smoking at home.,FAMILY HISTORY: , None noted exposures.,REVIEW OF SYSTEMS:  ,The patient is fed Enfamil, bottle-fed.  Has had decreased feeding, has had vomiting, has had diarrhea, otherwise negative on the 10 plus systems reviewed.,PHYSICAL EXAMINATION:,VITAL SIGNS/GENERAL:  On physical examination, the initial temperature 97.5, pulse 140, respirations 48 on this 2 kg 15-day-old female who is small, well-developed female, age appropriate.,HEENT: Head is atraumatic and normocephalic with a soft and flat anterior fontanelle.  Pupils are equal, round, and reactive to light.  Grossly conjugate.  Bilateral red reflex appreciated bilaterally.  Clear TMs, nose, and oropharynx.  There is a kind of abundant thrush and white patches on the tongue.,NECK:  Supple, full, painless, and nontender range of motion.,CHEST:  Clear to auscultation, equal, and stable.,HEART:  Regular without rubs or murmurs, and femoral pulses are appreciated bilaterally.,ABDOMEN:  Soft and nontender.  No hepatosplenomegaly or masses.,GENITALIA:  Female genitalia is present on a visual examination.,SKIN:  No significant bruising, lesions, or rash.,EXTREMITIES:  Moves all extremities, and nontender.  No deformity.,NEUROLOGICALLY:  Eyes open, moves all extremities, grossly age appropriate.,MEDICAL DECISION MAKING: , The differential entertained on this patient includes upper respiratory infection, gastroenteritis, urinary tract infection, dehydration, acidosis, and viral syndrome.  The patient is evaluated in the emergency department laboratory data, which shows a white blood cell count of 13.1, hemoglobin 14.0, platelets 267,000, 7 stabs, 68 segs, 15 lymphs, and 9 monos.  Serum electrolytes not normal.  Sodium 138, potassium 5.0, chloride 107, CO2 acidotic at 18, glucose normal at 88, and BUN markedly elevated at 22 as is the creatinine of 1.4.  AST and ALT were elevated as well at 412 and 180 respectively.  A cath urinalysis showing no signs of infection.  Spinal fluid evaluation, please see procedure note below.  White count 0, red count 2060.  Gram stain negative.,PROCEDURE NOTE: , After discussion of the risks, benefits, and indications, and obtaining informed consent with the family and their agreement to proceed, this patient was placed in the left lateral position and using aseptic Betadine preparation, sterile draping, and sterile technique pursued throughout, this patient's L4- L5 interspace was anesthetized with the 1% lidocaine solution following the above sterile preparation, entered with a 22-gauge styletted spinal needle of approximately 0.5 mL clear CSF, they were very slow to obtain.  The fluid was obtained, the needle was removed, and sterile bandage was placed.  The fluid was sent to laboratory for further evaluation (aunt and grandmother) were present throughout the period of time during this procedure and the procedure was tolerated well.  An i-STAT initially obtained showed somewhat of an acidosis with a base excess of -12.  A repeat i-STAT after a bolus of normal saline and a second bolus of normal saline, her maintenance rate of D5 half showed a base excess of -11, which is slowly improving, but not very fast.  Based on the above having this patient consulted to the Hospitalist Service at 2326 hours of request, this patient was consulted to PICU with the plan that the patient need to have continued IV fluids.  Showing signs of dehydration, a third bolus of normal saline was provided, twice maintenance D5 half was continued.  The patient was admitted to the Hospitalist Service for continued IV fluids.  The patient maintains to have clear lungs, has been feeding well here in the department, took virtually a whole small bottle of the appropriate formula.  She has not had any vomiting, is burping.  The patient is admitted for continued close observation and rehydration due to the working diagnoses of gastroenteritis, metabolic acidosis, and dehydration.  Critical care time on this patient is less than 30 minutes, exclusive, otherwise time has been spent evaluating this patient according to this patient's care and admission to the Hospitalist Service.
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DESCRIPTION: Consult and Spinal fluid evaluation in a 15-day-old

The situation described involves a 15-day-old infant presenting with potentially serious medical symptoms requiring evaluation at a children's hospital. The symptoms include vomiting, diarrhea, metabolic acidosis, elevated white blood cell count, and other critical lab findings. Spinal fluid evaluation and multiple diagnoses such as gastroenteritis, metabolic acidosis, and dehydration suggest a potentially critical health issue. Infants are particularly vulnerable due to their developmental stage and inability to communicate, making accurate diagnosis and treatment time-sensitive and crucial for avoiding severe outcomes. Therefore, the stakes are high as this involves the health and wellbeing of a newborn.


Medical Specialty: Surgery
Sample Name: Cystolithalopaxy

PREOPERATIVE DIAGNOSES:,1.  Prostatism.,2.  Bladder calculus.,OPERATION:,  Holmium laser cystolithalopaxy.,POSTOPERATIVE DIAGNOSES:,1.  Prostatism.,2.  Bladder calculus.,ANESTHESIA:  ,General.,INDICATIONS:,  This is a 62-year-old male diabetic and urinary retention with apparent neurogenic bladder and intermittent self-catheterization, recent urinary tract infections.  The cystoscopy showed a large bladder calculus, short but obstructing prostate.  He comes in now for transurethral resection of his prostate and holmium laser cystolithotripsy.,He is a diabetic with obesity.,LABORATORY DATA:  ,Includes urinalysis showing white cells too much to count, 3-5 red cells, occasional bacteria.  He had a serum creatinine of 1.2, sodium 138, potassium 4.6, glucose 190, calcium 9.1.  Hematocrit 40.5, hemoglobin 13.8, white count 7,900.,PROCEDURE: , The patient was satisfactorily given general anesthesia.  Prepped and draped in the dorsal lithotomy position.  A 27-French Olympus rectoscope was passed via the urethra into the bladder.  The bladder, prostate, and urethra were inspected.  He had an obstructing prostate.  He had marked catheter reaction in his bladder.  He had a lot of villous changes, impossible to tell from frank tumor.  He had a huge bladder calculus.  It was white and round.,I used the holmium laser with the largest fiber through the continuous flow resectoscope and sheath, and broke up the stone, breaking up approximately 40 grams of stone.  There was still stone left at the end of the procedure.  Most of the chips that could be irrigated out of the bladder were irrigated out using Ellik.,Then the scope was removed and a 24-French 3-way Foley catheter was passed via the urethra into the bladder.,The plan is to probably discharge the patient in the morning and then we will get a KUB.  We will probably bring him back for a second stage cystolithotripsy, and ultimately do a TURP.  We broke up the stone for over an hour, and my judgment continuing with litholapaxy transurethrally over an hour begins to markedly increase the risk to the patient.
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DESCRIPTION: Holmium laser cystolithalopaxy.  A diabetic male in urinary retention with apparent neurogenic bladder and intermittent self-catheterization, recent urinary tract infections.  The cystoscopy showed a large bladder calculus, short but obstructing prostate.

surgery, prostatism, holmium laser cystolithalopaxy, urinary tract infections, holmium laser, bladder calculus, bladder, cystolithalopaxy, diabetic, urethra, urinary, catheterization, stone, calculus, prostate,

The situation involves a surgical procedure (Holmium laser cystolithalopaxy) on a patient with multiple risk factors, notably diabetes, obesity, neurogenic bladder, intermittent self-catheterization, urinary retention, and recent urinary tract infections. The presence of a large bladder calculus and the need for further surgical intervention to clear remaining stones underscore the complexity and potential risks involved. The mention of increased risk if the procedure continued much longer further highlights the high-stakes nature of the situation. Additionally, the patient needs close monitoring post-procedure, indicating the critical nature of the case and the potential for complications both during and after the surgery.


Medical Specialty: Pediatrics - Neonatal
Sample Name: Circumcision - Infant

PROCEDURE: , Circumcision.,PRE-PROCEDURE DIAGNOSIS: , Normal male phallus.,POST-PROCEDURE DIAGNOSIS: , Normal male phallus.,ANESTHESIA:  ,1% lidocaine without epinephrine.,INDICATIONS: , The risks and benefits of the procedure were discussed with the parents.  The risks are infection, hemorrhage, and meatal stenosis.  The benefits are ease of care and cleanliness and fewer urinary tract infections.  The parents understand this and have signed a permit.,FINDINGS: , The infant is without evidence of hypospadias or chordee prior to the procedure.,TECHNIQUE:  ,The infant was given a dorsal penile block with 1% lidocaine without epinephrine using a tuberculin syringe and 0.5 cc of lidocaine was delivered subcutaneously at 10:30 and at 1:30 o'clock at the dorsal base of the penis.,The infant was prepped then with Betadine and draped with a sterile towel in the usual manner.  Clamps were placed at 10 o'clock and 2 o'clock and the adhesions between the glans and mucosa were instrumentally lysed.  Dorsal hemostasis was established and a dorsal slit was made.  The foreskin was fully retracted and remaining adhesions between the glans and mucosa were manually lysed.  The infant was fitted with a XX-cm Plastibell.  The foreskin was retracted around the Plastibell and circumferential hemostasis was established.  The excess foreskin was removed with scissors and the infant tolerated the procedure well with a minimum amount of blood loss.  Instructions for continuing care are to watch for any evidence of hemorrhage or urination and the parents are instructed in the care of the circumcised penis.
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DESCRIPTION: Circumcision.  Normal male phallus.   The infant is without evidence of hypospadias or chordee prior to the procedure.

pediatrics - neonatal, dorsal slit, hypospadias, chordee, epinephrine, hemorrhage, penis, adhesions, circumcision, phallus, lidocaine, foreskin, infant

The procedure described is an infant circumcision, which is a common and generally low-risk surgical procedure when performed by trained medical professionals. Although it has associated risks like any surgical procedure, such as infection or hemorrhage, these are relatively rare, and the procedure is regularly performed safely in clinical settings. The parental consent has been obtained, and the described technique shows adherence to sterile procedures. However, while it is common, it involves ethical considerations and ongoing debates regarding necessity which may heighten perceived stakes for some parents. Still, in terms of medical risk, it is not extremely high-stakes.