Medical Specialty: Radiology
Sample Name: EMG/Nerve Conduction Study - 2

HISTORY: , The patient is a 78-year-old right-handed inpatient with longstanding history of cervical spinal stenosis status post decompression, opioid dependence, who has had longstanding low back pain radiating into the right leg.  She was undergoing a spinal epidural injection about a month ago and had worsening of right low back pain, which radiates down into her buttocks and down to posterior aspect of her thigh into her knee.  This has required large amounts of opioid analgesics to control.  She has been basically bedridden because of this.  She was brought into hospital for further investigations.,PHYSICAL EXAMINATION: , On examination, she has positive straight leg rising on the right with severe shooting, radicular type pain with right leg movement.  Difficult to assess individual muscles, but strength is largely intact.  Sensory examination is symmetric.  Deep tendon reflexes reveal hyporeflexia in both patellae, which probably represents a cervical myelopathy from prior cord compression.  She has slightly decreased right versus left ankle reflexes.  The Babinski's are positive.  On nerve conduction studies, motor and sensory distal latencies, evoked response amplitudes, conduction velocities, and F-waves are normal in lower extremities.,NEEDLE EMG: , Needle EMG was performed on the right leg and lumbosacral paraspinal muscles using a disposable concentric needle.  It reveals the spontaneous activity in right peroneus longus and gastrocnemius medialis muscles as well as the right lower lumbosacral paraspinal muscles.  There is evidence of denervation in right gastrocnemius medialis muscle.,IMPRESSION: , This electrical study is abnormal.  It reveals the following:,1.  Inactive right S1 (L5) radiculopathy.,2.  There is no evidence of left lower extremity radiculopathy, peripheral neuropathy or entrapment neuropathy.,Results were discussed with the patient and she is scheduled for imaging studies in the next day.
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DESCRIPTION: A ight-handed inpatient with longstanding history of cervical spinal stenosis status post decompression, opioid dependence, who has had longstanding low back pain radiating into the right leg.

radiology, needle emg, radiculopathy, electrical study, emg, nerve conduction study, cervical spinal stenosis, lumbosacral paraspinal muscles, gastrocnemius medialis muscles, spinal stenosis, post decompression, lumbosacral paraspinal, paraspinal muscles, gastrocnemius medialis, medialis muscles, decompression, emg/nerve, conduction, cervical, spinal, needle, muscles,

The situation involves a 78-year-old patient with a complex medical history, including cervical spinal stenosis, opioid dependence, and debilitating pain that has left her bedridden. While these conditions present significant challenges, the context is a scheduled EMG/Nerve Conduction study with no immediate life-threatening implications noted. The test revealed right S1 (L5) radiculopathy, confirming a structural issue but not currently threatening the patient's life. However, the ongoing use of opioids due to severe pain adds a layer of complexity. The stakes are moderately high due to the current impact on her quality of life and the potential complications if unmanaged. However, given the structured hospital environment and ongoing investigations, it is not as immediately critical as a situation with severe acute or unstable medical conditions.


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

Medical Specialty: Hematology - Oncology
Sample Name: Glioblastoma Multiforme - Consult

REASON FOR CONSULTATION: , We were asked to see the patient in regards to a brain tumor.,HISTORY OF PRESENT ILLNESS: ,She was initially diagnosed in September of this year with a glioblastoma multiforme.  She presented with several lesions in her brain and a biopsy confirmed the diagnosis.  She was seen by Dr. X in our group.  Because of her living arrangement, she elected to have treatment through the hospital radiation department and oncology department.  Details of her treatment are not available at the time of this dictation.  Her family has a packet of Temodar 100-mg pills.  She is admitted now with increasing confusion.  A CT shows increase in size of the lesions compared to the preoperative scan.  We are asked to comment on her treatment at this point.  She herself is confused and is unable to provide further history.  ,PAST MEDICAL HISTORY: , From her old chart:  No known past medical history prior to the diagnosis.,SOCIAL HISTORY:  ,She was living alone and is now living in assisted living.  ,MEDICATIONS,1.  Dilantin 300 mg daily.,2.  Haloperidol 1 mg h.s.,3.  Dexamethasone 4 mg q.i.d. ,4.  Docusate 100 mg b.i.d.,5.  Pen-VK 500 mg daily.,6.  Ibuprofen 600 mg daily.,7.  Zantac 150 mg twice a day.,8.  Temodar 100 mg daily.,9.  Magic Mouthwash daily.,10.  Tylenol #3 as needed.,REVIEW OF SYSTEMS,:  Unable.,PHYSICAL EXAMINATION,GENERAL:  Elderly woman, confused.  ,HEENT:  Normal conjunctivae.  Ears and nose normal.  Mouth normal.,NECK:  Supple.,CHEST: Clear.,HEART:  Normal.,ABDOMEN: Soft, positive bowel sounds.,NEUROLOGIC:  Alert, cranial nerves intact.  Left arm slightly weak.  Left leg slightly weak.,IMPRESSION AND PLAN:,  Glioblastoma multiforme, uncertain as to where she is in cancer treatment.  Given the number of pills in the patient's family's hands, it sounds like she has only been treated recently and therefore it is not surprising that she is showing increased problems related to increased size of the tumor.  We will have to talk with Dr. Y in the Clinic to get a better handle on her treatment regimen.  At this point, I will hold Temodar today and consider restarting it tomorrow if we can get her treatment plan clarified.
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DESCRIPTION: Asked to see the patient in regards to a brain tumor.  She was initially diagnosed with a glioblastoma multiforme.  She presented with several lesions in her brain and a biopsy confirmed the diagnosis.

The situation involves a consultation for a patient with glioblastoma multiforme, which is a highly aggressive and severe type of brain tumor. The patient shows increasing confusion, indicative of worsening symptoms, which may require immediate medical intervention. The patient's unclear treatment status adds to the urgency of the situation, as it could impact the decisions regarding the continuation or adjustment of current treatment plans. Therefore, the situation is high-stakes due to the potential implications for the patient's health and treatment outcomes.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Orthopedic
Sample Name: Knee Amputation

PREOPERATIVE DIAGNOSES:,1.  Left diabetic foot abscess and infection.,2.  Left calcaneus fracture with infection.,3.  Right first ray amputation.,POSTOP DIAGNOSES:,1.  Left diabetic foot abscess and infection.,2.  Left calcaneus fracture with infection.,3.  Right first ray amputation.,OPERATION AND PROCEDURE:,1.  Left below-the-knee amputation.,2.  Dressing change, right foot.,ANESTHESIA: , General.,BLOOD LOSS: , Less than 100 mL.,TOURNIQUET TIME:,  24 minutes on the left, 300 mmHg.,COMPLICATIONS:,  None.,DRAINS: , A one-eighth-inch Hemovac.,INDICATIONS FOR SURGERY: , The patient is a 62 years of age with diabetes.  He developed left heel abscess.  He had previous debridements, developed a calcaneal fracture and has now had several debridement with placement of the antibiotic beads.  After re-inspecting the wound last week, the plan was for possible debridement and he desired below-the-knee amputation.  We are going to change the dressing on the right side also.  The risks, benefits, and alternatives of surgery were discussed.  The risks of bleeding, infection, damage to nerves and blood vessels, persistent wound healing problems, and the need for future surgery.  He understood all the risks and desired operative treatment.,OPERATIVE PROCEDURE IN DETAIL: , After appropriate informed consent obtained, the patient was taken to the operating room and placed in the supine position.  General anesthesia induced.  Once adequate anesthesia had been achieved, cast padding placed on the left proximal thigh and tourniquet was applied.  The right leg was redressed.  I took the dressing down.  There was a small bit of central drainage, but it was healing nicely.  Adaptic and new sterile dressings were applied.,The left lower extremity was then prepped and draped in usual sterile fashion.,A transverse incision made about the mid shaft of the tibia.  A long posterior flap was created.  It was taken to the subcutaneous tissues with electrocautery.  Please note that tourniquet had been inflated after exsanguination of the limb.  Superficial peroneal nerve identified, clamped, and cut.  Anterior compartment was divided.  The anterior neurovascular bundle identified, clamped, and cut.  The plane was taken between the deep and superficial compartments.  The superficial compartment was reflected posteriorly.  Tibial nerve identified, clamped, and cut.  Tibial vessels identified, clamped, and cut.,Periosteum of the tibia elevated proximally along with the fibula.  The tibia was then cut with Gigli saw.  It was beveled anteriorly and smoothed down with a rasp.  The fibula was cut about a cm and a half proximal to this using a large bone cutter.  The remaining posterior compartment was divided.  The peroneal bundle identified, clamped, and cut.  The leg was then passed off of the field.  Each vascular bundle was then doubly ligated with 0 silk stick tie and 0 silk free tie.  The nerves were each pulled at length, injected with 0.25% Marcaine with epinephrine, cut, and later retracted proximally.  The tourniquet was released.  Good bleeding from the tissues and hemostasis obtained with electrocautery.  Copious irrigation performed using antibiotic-impregnated solution.  A one-eighth-inch Hemovac drain placed in the depth of wound adhering on the medial side.  A gastroc soleus fascia brought up and attached to the anterior fascia and periosteum with #1 Vicryl in an interrupted fashion.  The remaining fascia was closed with #1 Vicryl.  Subcutaneous tissues were then closed with 2-0 PDS suture using 2-0 Monocryl suture in interrupted fashion.  Skin closed with skin staples.  Xeroform gauze, 4 x 4, and a padded soft dressing applied.  He was placed in a well-padded anterior and posterior slab splint with the knee in extension.  He was then awakened, extubated, and taken to recovery in stable condition.  There were no immediate operative complications, and he tolerated the procedure well.
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DESCRIPTION: Left below-the-knee amputation.  Dressing change, right foot.

orthopedic, infection, adaptic, gigli saw, hemovac, abscess, amputation, below-the-knee amputation, calcaneus fracture, debridement, diabetic foot, ray amputation, tourniquet, transverse incision, knee amputation, knee, dressing, clamped,

The situation involves a below-the-knee amputation for a patient with a diabetic foot abscess and calcaneus fracture with infection. Amputations are serious surgical procedures often indicated when there's a significant risk of life-threatening infections or when limb salvage is not viable. The procedure indicates a high-stakes scenario due to the major impact on the patient's life, the complexity of the surgery, and the presence of diabetes, which complicates healing and increases risks.


Medical Specialty: Surgery
Sample Name: Colonoscopy With Photos

PREOPERATIVE DIAGNOSIS: , Blood loss anemia.,POSTOPERATIVE DIAGNOSES:,1.  Diverticulosis coli.,2.  Internal hemorrhoids.,3.  Poor prep.,PROCEDURE PERFORMED:,  Colonoscopy with photos.,ANESTHESIA: , Conscious sedation per Anesthesia.,SPECIMENS:,  None.,HISTORY:,  The patient is an 85-year-old female who was admitted to the hospital with a markedly decreased hemoglobin and blood loss anemia.  She underwent an EGD and attempted colonoscopy; however, due to a very poor prep, only a flexible sigmoidoscopy was performed at that time.  A coloscopy is now being performed for completion.,PROCEDURE:,  After proper informed consent was obtained, the patient was brought to the Endoscopy Suite.  She was placed in the left lateral position and was given sedation by the Anesthesia Department.  A digital rectal exam was performed and there was no evidence of mass.  The colonoscope was then inserted into the rectum.  There was some solid stool encountered.  The scope was maneuvered around this.  There was relatively poor prep as the scope was advanced through the sigmoid colon and portions of the descending colon.  The scope was then passed through the transverse colon and ascending colon to the cecum.  No masses or polyps were noted.  Visualization of the portions of the colon was however somewhat limited.  There were scattered diverticuli noted in the sigmoid.,The scope was slowly withdrawn carefully examining all walls.  Once in the rectum, the scope was retroflexed and nonsurgical internal hemorrhoids were noted.  The scope was then completely withdrawn.  The patient tolerated the procedure well and was transferred to recovery room in stable condition.  She will be placed on a high-fiber diet and Colace and we will continue to monitor her hemoglobin.
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DESCRIPTION: Colonoscopy with photos.  The patient is an 85-year-old female who was admitted to the hospital with a markedly decreased hemoglobin and blood loss anemia.  She underwent an EGD and attempted colonoscopy; however, due to a very poor prep, only a flexible sigmoidoscopy was performed at that time.  A coloscopy is now being performed for completion.

surgery, blood loss anemia, diverticulosis coli, internal hemorrhoids, poor prep, colonoscopy, sigmoidoscopy, hemoglobin, coloscopy, colonoscopy with photos, attempted colonoscopy, flexible sigmoidoscopy, photos, anemia, scope

The situation involves a medical procedure on an 85-year-old patient with blood loss anemia, which requires careful attention due to the patient's age and condition. However, the immediate stakes are relatively low because the procedure was completed without complications, and the patient tolerated it well, with no urgent findings such as masses or polyps. Follow-up care has been planned with dietary adjustments and monitoring. While there are inherent risks in medical procedures, particularly in older patients, this scenario does not depict an emergency or a critical situation.


Medical Specialty: Surgery
Sample Name: Tracheostomy & Thyroid Isthmusectomy

PREOPERATIVE DIAGNOSES:,1.  Ventilator-dependent respiratory failure.,2.  Multiple strokes.,POSTOPERATIVE DIAGNOSES:,1.  Ventilator-dependent respiratory failure.,2.  Multiple strokes.,PROCEDURES PERFORMED:,1.  Tracheostomy.,2.  Thyroid isthmusectomy.,ANESTHESIA: , General endotracheal tube.,BLOOD LOSS: , Minimal, less than 25 cc.,INDICATIONS:,  The patient is a 50-year-old gentleman who presented to the Emergency Department who had had multiple massive strokes.  He had required ventilator assistance and was transported to the ICU setting.  Because of the numerous deficits from the stroke, he is expected to have a prolonged ventilatory course and he will be requiring long-term care.,PROCEDURE: , After all risks, benefits, and alternatives were discussed with multiple family members in detail, informed consent was obtained.  The patient was brought to the Operative Suite where he was placed in supine position and general anesthesia was delivered through the existing endotracheal tube.  The neck was then palpated and marked appropriately in the cricoid cartilage sternal notch and thyroid cartilage marked appropriately with felt-tip marker.  The skin was then anesthetized with a mixture of 1% lidocaine and 1:100,000 epinephrine solution.  The patient was prepped and draped in usual fashion.  The surgeons were gowned and gloved.  A vertical skin incision was then made with a #15 blade scalpel extending from approximately two fingerbreadths above the level of the sternum approximately 1 cm above the cricoid cartilage.  Blunt dissection was then carried down until the fascia overlying the strap muscles were identified.  At this point, the midline raphe was identified and the strap muscles were separated utilizing the Bovie cautery.  Once the strap muscles have been identified, palpation was performed to identify any arterial aberration.  A high-riding innominate was not identified.  At this point, it was recognized that the thyroid gland was overlying the trachea could not be mobilized.  Therefore, dissection was carried down through to the cricoid cartilage at which point hemostat was advanced underneath the thyroid gland, which was then doubly clamped and ligated with Bovie cautery.  Suture ligation with #3-0 Vicryl was then performed on the thyroid gland in a double interlocking fashion.  This cleared a significant portion of the trachea.  The overlying pretracheal fascia was then cleared with use of pressured forceps as well as Bovie cautery.  Now, a tracheal hook was placed underneath the cricoid cartilage in order to stabilize the trachea.  The second tracheal ring was identified.  The Bovie cautery reduced to create a tracheal window beneath the second tracheal ring that was inferiorly based.  At this point, the anesthetist was appropriately alerted to deflate the endotracheal tube cuff.  The airway was entered and inferior to the base, window was created.  The anesthetist then withdrew the endotracheal tube until the tip of the tube was identified.  At this point, a #8 Shiley tracheostomy tube was inserted freely into the tracheal lumen.  The balloon was inflated and the ventilator was attached.  He was immediately noted to have return of the CO2 waveform and was ventilating appropriately according to the anesthetist.  Now, all surgical retractors were removed.  The baseplate of the tracheostomy tube was sutured to the patient's skin with #2-0 nylon suture.  The tube was further secured around the patient's neck with IV tubing.  Finally, a drain sponge was placed.  At this point, procedure was felt to be complete.  The patient was returned to the ICU setting in stable condition where a chest x-ray is pending.
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DESCRIPTION: Tracheostomy and thyroid isthmusectomy.  Ventilator-dependent respiratory failure and multiple strokes.

surgery, ventilator-dependent respiratory failure, multiple strokes, thyroid, thyroid isthmusectomy, ventilator dependent, respiratory failure, strap muscles, thyroid gland, endotracheal tube, cricoid cartilage, bovie cautery, tracheostomy, ventilator, strokes, cartilage, tracheal, isthmusectomy

The procedure described involves a tracheostomy and thyroid isthmusectomy on a patient with a complex medical history, including ventilator-dependent respiratory failure and multiple strokes. Tracheostomy is a critical surgical procedure typically performed in high-stakes situations to secure an airway for patients with significant respiratory challenges. The patient's condition, which includes multiple strokes and ventilator dependency, indicates an acute need for securing a stable airway, contributing to the high-stakes nature of this situation. Additionally, the procedure involves general anesthesia and requires precise surgical techniques to avoid complications. The stakes are elevated due to the vital nature of the airway management and the patient's fragile health status.


Medical Specialty: Surgery
Sample Name: Colonoscopy - 4

PREOPERATIVE DIAGNOSIS:,  Diarrhea, suspected irritable bowel.,POSTOPERATIVE DIAGNOSIS:,  Normal colonoscopy., PREMEDICATIONS: , Versed 5 mg, Demerol 75 mg IV.,REPORTED PROCEDURE:,  The rectal exam revealed no external lesions.  The prostate was normal in size and consistency.,The colonoscope was inserted into the cecum with ease.  The cecum, ascending colon, hepatic flexure, transverse colon, splenic flexure, descending colon, sigmoid colon, and rectum were normal.  The scope was retroflexed in the rectum and no abnormality was seen, so the scope was straightened, withdrawn, and the procedure terminated.,ENDOSCOPIC IMPRESSION:,  Normal colonoscopy - no evidence of inflammatory disease, polyp, or other neoplasm.  These findings are certainly consistent with irritable bowel syndrome.
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DESCRIPTION: Colonoscopy - Diarrhea, suspected irritable bowel

surgery, diarrhea, ascending colon, cecum, colonoscope, colonoscopy, descending colon, hepatic flexure, inflammatory disease, irritable bowel syndrome, irritable bowel., polyp, rectal exam, rectum, sigmoid colon, splenic flexure, transverse colon, normal colonoscopy, irritable bowel, flexure, irritable, bowel,

The situation involves a routine colonoscopy, which is a common procedure to investigate issues like diarrhea and irritable bowel syndrome. The postoperative diagnosis indicates a normal result without any complications such as inflammation, polyps, or neoplasms. Routine medical procedures with normal results generally do not carry high stakes. Furthermore, there is no indication of cancer or severe disease in the findings, which reduces the urgency or critical nature of the situation.


Medical Specialty: Surgery
Sample Name: Lumbar Discogram

PREOPERATIVE DIAGNOSIS: , Low back pain.,POSTOPERATIVE DIAGNOSIS: , Low back pain.,PROCEDURE PERFORMED:,1.  Lumbar discogram L2-3.,2.  Lumbar discogram L3-4.,3.  Lumbar discogram L4-5.,4.  Lumbar discogram L5-S1.,ANESTHESIA:  ,IV sedation.,PROCEDURE IN DETAIL:  ,The patient was brought to the Radiology Suite and placed prone onto a radiolucent table.  The C-arm was brought into the operative field and AP, left right oblique and lateral fluoroscopic images of the L1-2 through L5-S1 levels were obtained.  We then proceeded to prepare the low back with a Betadine solution and draped sterile.  Using an oblique approach to the spine, the L5-S1 level was addressed using an oblique projection angled C-arm in order to allow for perpendicular penetration of the disc space.  A metallic marker was then placed laterally and a needle entrance point was determined.  A skin wheal was raised with 1% Xylocaine and an #18-gauge needle was advanced up to the level of the disc space using AP, oblique and lateral fluoroscopic projections.  A second needle, #22-gauge 6-inch needle was then introduced into the disc space and with AP and lateral fluoroscopic projections, was placed into the center of the nucleus.  We then proceeded to perform a similar placement of needles at the L4-5, L3-4 and L2-3 levels.,A solution of Isovue 300 with 1 gm of Ancef was then drawn into a 10 cc syringe and without informing the patient of our injecting, we then proceeded to inject the disc spaces sequentially.
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DESCRIPTION: Lumbar discogram L2-3, L3-4, L4-5, and L5-S1.  Low back pain.

surgery, back pain, c-arm, fluoroscopic projections, disc space, lumbar discogram, fluoroscopic, needle,

A lumbar discogram is a diagnostic procedure where dye is injected into the spinal disc to identify sources of back pain. While this procedure is invasive and requires careful execution, it is relatively routine and does not involve immediate or life-threatening risks, especially with experienced practitioners. It is high-stakes only in the context that it needs precision and careful handling to avoid complications such as infection or worsening of symptoms. However, these outcomes are not common with standard precautions followed. Thus, in the realm of surgical procedures, particularly those concerning the spine, it is of moderate stakes primarily due to the need for precision.


Medical Specialty: Surgery
Sample Name: Pectoralis Tendon Repair

PREOPERATIVE DIAGNOSIS: , Right pectoralis major tendon rupture.,POSTOPERATIVE DIAGNOSIS: , Right pectoralis major tendon rupture.,OPERATION PERFORMED: , Open repair of right pectoralis major tendon.,ANESTHESIA:,  General with an interscalene block.,COMPLICATIONS:,  None.,Needle and sponge counts were done and correct.,INDICATION FOR OPERATION:  ,The patient is a 26-year-old right hand dominant male who works in sales, who was performing heavy bench press exercises when he felt a tearing burning pain severe in his right shoulder.  The patient presented with mild bruising over the proximal arm of the right side with x-ray showing no fracture.  Over concerns for pectoralis tendon tear, he was sent for MRI evaluation where a complete rupture of a portion of the pectoralis major tendon was noted.  Due to the patient's young age and active lifestyle surgical treatment was recommended in order to obtain best result.  The risks and benefits of the procedure were discussed in detail with the patient including, but not limited to scarring, infection, damage to blood vessels and nerves, re-rupture, need further surgery, loss of range of motion, inability to return to heavy activity such as weight lifting, complex usual pain syndrome, and deep vein thrombosis as well as anesthetic risks.  Understanding all risks and benefits, the patient desires to proceed with surgery as planned.,FINDINGS:,1.  Following deltopectoral approach to the right shoulder, the pectoralis major tendon was encountered.  The clavicular head was noted to be intact.  There was noted to be complete rupture of the sternal head of the pectoralis major tendon with an oblique-type tear having some remaining cuff on the humerus and some tendon attached to the retracted portion.,2.  Following freeing of adhesions using tracks and sutures, the pectoralis major tendon was able to reapproximated to its insertion site on the humerus just lateral to the biceps.,3.  A soft tissue repair was performed with #5 FiberWire suture and a single suture anchor of 5 x 5 bioabsorbable anchor was placed in order to decrease tension at the repair site.  Following repair of soft tissue and using the bone anchor, there was noted to be good apposition of the tendon with edges and a solid repair.,OPERATIVE REPORT IN DETAIL: , The patient was identified in the preop holding area.  His right shoulder was identified, marked his appropriate surgical site after verification with the patient.  He was then taken to the operating room where he was transferred to the operative table in supine position and placed under general anesthesia by anesthesiology team.  He then received prophylactic antibiotics.  A time-out was then undertaken verifying the correct patient, extremity, surgery performed, administration of antibiotics, and the availability of equipment.  At this point, the patient was placed to a modified beech chair position with care taken to ensure all appropriate pressure points were padded and there was no pressure over the eyes.  The right upper extremity was then prepped and draped in the usual sterile fashion.  Preoperative markings were still visible at this point.  A deltopectoral incision was made utilizing the inferior portion.  Dissection was carried down.  The deltoid was retracted laterally.  The clavicular head of the pectoralis major was noted to be intact with the absence of the sternal insertion.  There was a small cuff of tissue left on the proximal humerus associated with the clavicular head.  Gentle probing medially revealed the end of the sternal retracted portion, traction sutures of #5 Ethibond were used in this to allow for retraction and freeing from light adhesion.  This allowed reapproximation of the retracted tendon to the tendon stump.  At this point, a repair using #5 FiberWire was then performed of the pectoralis major tendon back to stump on the proximal humerus noting good apposition of the tendon edges and no gapping of the repair site.  At this point, a single metal suture anchor was attempted to be implanted just lateral to the insertion of the pectoralis in order to remove tension off the repair site; however, the inserted device attached to the metal anchor broke during insertion due to significant hardness of the bone.  For this reason, the starting hole was tapped and a 5x5 bioabsorbable anchor was placed, doubly loaded.  The sutures were then weaved through the lateral aspect of the torn tendon and a modified Krackow type performed and sutured thereby relieving tension off the soft tissue repair.  At this point, there was noted to be excellent apposition of the soft tissue ends and a solid repair to gentle manipulation.  Aggressive external rotation was not performed.  The wound was then copiously irrigated.  The cephalic vein was not injured during the case.  The skin was then closed using a 2-0 Vicryl followed by a 3-0 subcuticular Prolene suture with Steri-Strips.  Sterile dressing was then placed.  Anesthesia was then performed, interscalene block.  The patient was then awakened from anesthesia and transported to postanesthesia care in stable condition in a shoulder immobilizer with the arm adducted and internally rotated.,Plan for this patient, the patient will remain in the shoulder immobilizer until followup visit in approximately 10 days.  We will then start a gentle Codman type exercises and having limited motion until the 4-6 week point based on the patient's progression.
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DESCRIPTION: Open repair of right pectoralis major tendon.   Right pectoralis major tendon rupture.  On MRI evaluation, a complete rupture of a portion of the pectoralis major tendon was noted.

surgery, tendon rupture, interscalene block, pectoralis major tendon rupture, pectoralis major tendon, repair, pectoralis, interscalene, tendon, rupture, sutures,

The situation described involves a surgical procedure to repair a complete rupture of the pectoralis major tendon. While the surgery is important for the patient's recovery and future physical capabilities, particularly considering the patient's active lifestyle, it is not inherently life-threatening. Surgical risks are present, as with any operation, but they are outlined and appear to be managed well. Additionally, the surgery was performed without complications, indicating a standard procedure rather than an emergency or high-risk situation.


Medical Specialty: Surgery
Sample Name: Circumcision - Child

PROCEDURE: , Circumcision.,Signed informed consent was obtained and the procedure explained.,The child was placed in a Circumstraint board and restrained in the usual fashion.  The area of the penis and scrotum were prepared with povidone iodine solution.  The area was draped with sterile drapes, and the remainder of the procedure was done with sterile procedure.  A dorsal penile block was done using 2 injections of 0.3 cc each, 1% plain lidocaine.  A dorsal slit was made, and the prepuce was dissected away from the glans penis.  A ** Gomco clamp was properly placed for 5 minutes.  During this time, the foreskin was sharply excised using a #10 blade.  With removal of the clamp, there was a good cosmetic outcome and no bleeding.  The child appeared to tolerate the procedure well.  Care instructions were given to the parents.
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DESCRIPTION: Circumcision.  The child appeared to tolerate the procedure well.  Care instructions were given to the parents.

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

Circumcision in children, while a common and routine surgical procedure, still carries risks such as infection and bleeding, which require careful attention and sterile techniques. Furthermore, the procedure requires informed consent and appropriate follow-up care instructions for the parents. These factors make it a moderately high-stakes situation due to the need to prevent complications and ensure proper healing.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Pathology - Ovarian Cyst

GROSS DESCRIPTION: ,  Specimen labeled "right ovarian cyst" is received fresh for frozen section.  It consists of a smooth-walled, clear fluid filled cyst measuring 13x12x7 cm and weighing 1351 grams with fluid.  Both surfaces of the wall are pink-tan, smooth and grossly unremarkable.  No firm or thick areas or papillary structures are noted on the cyst wall externally or internally.  After removal the fluid, the cyst weight 68 grams.  The fluid is transparent and slightly mucoid.  A frozen section is submitted.,DIAGNOSIS: , Benign cystic ovary.,
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DESCRIPTION: Specimen labeled "right ovarian cyst" is received fresh for frozen section.

obstetrics / gynecology, right ovarian cyst, specimen, ovarian cyst, frozen section, ovarian, frozen, sectionNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.

The situation involves the analysis of a right ovarian cyst, which is a common occurrence in the field of Obstetrics and Gynecology. The gross description and the diagnosis indicated that the cyst is benign. While it is important for patient management and treatment planning, it is a routine procedure and the cyst being benign reduces the risk associated with the situation. Since the cyst is not malignant, the situation is not immediately life-threatening or urgent, reducing the overall stakes.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Dietary Consult - Diabetes - 1

SUBJECTIVE:,  This is a 28-year-old female who comes for dietary consultation for diabetes during pregnancy.  Patient reports that she had gestational diabetes with her first pregnancy.  She did use insulin at that time as well.  She does not fully understand what ketones are.  She walks her daughter to school and back home each day which takes 20 minutes each way.  She is not a big milk drinker, but she does try to drink some.,OBJECTIVE:,  Weight is 238.3 pounds.  Weight from last week’s visit was 238.9 pounds.  Prepregnancy weight is reported at 235 pounds.  Height is 62-3/4 inches.  Prepregnancy BMI is approximately 42-1/2.  Insulin schedule is NovoLog 70/30, 20 units in the morning and 13 units at supper time.  Blood sugar records for the last week reveal the following:  Fasting blood sugars ranging from 92 to 104 with an average of 97, two-hour postprandial breakfast readings ranging from 172 to 196 with an average of 181, two-hour postprandial lunch readings ranging from 149 to 189 with an average of 168 and two-hour postprandial dinner readings ranging from 109 to 121 with an average of 116.  Overall average is 140.  A diet history was obtained.  Expected date of confinement is May 1, 2005.  Instructed the patient on dietary guidelines for gestational diabetes.  A 2300 meal plan was provided and reviewed.  The Lily Guide for Meal Planning was provided and reviewed.,ASSESSMENT:,  Patient’s basal energy expenditure adjusted for obesity is estimated at 1566 calories a day.  Her total calorie requirements, including physical activity factors as well as additional calories for pregnancy, totals 2367 calories a day.  Her diet history reveals that she is eating three meals a day and three snacks.  The snacks were just added last week following presence of ketones in her urine.  We identified carbohydrate sources in the food supply, recognizing that they are the foods that raise blood sugar the most.  We identified 15 gram equivalents of carbohydrate and established a carbohydrate budget.  We also discussed the goal of balancing food intake with blood sugar control and adequate caloric intake to sustain appropriate weight gain for the pregnancy of 1/2 a pound a week through the duration of the pregnancy.  We discussed the physiology of ketone production from inadequate calories or inadequate insulin and elevated blood sugars.  While a sample meal plan was provided reflecting the patient’s carbohydrate budget I emphasized the need for her to eat according to her appetite, but to work at consistency in the volume of carbohydrates consumed at a given meal or a given snack from day to day.  Patient was assured that we can titrate the insulin to match whatever eating pattern is suitable for her as long as she can do it on a consistent basis.  At the same time she was encouraged to continue to eliminate the more concentrated forms of refined carbohydrates.,PLAN:,  Recommend the patient work with the following meal plan with a carbohydrate budget representing approximately 45% of the calories from carbohydrate.  Breakfast:  Three carbohydrate servings.  Morning snack:  One carbohydrate serving.  Lunch:  Four carbohydrate servings.  Afternoon snack:  One carbohydrate serving.  Supper:  Four carbohydrate servings.  Bedtime snack:  One carbohydrate serving.  Encouraged patient to include some solid protein with each of her meals as well as with the bedtime snack.  Encouraged three servings of dairy products per day to meet nutritional needs for calcium during pregnancy.  Recommend patient include a fruit or a vegetable with most of her meals.  Also recommend including solid protein with each meal as well as with the bedtime snack.  Charlie Athene reviewed blood sugars at this consultation as well, and made the following insulin adjustment:  Morning 70/30, will increase from 20 units up to 24 units and evening 70/30, we will increase from 13 units up to 16 units.  Patient was encouraged to call in blood sugars at the end of the week if they are outside of the range of over 90 fasting and over 120 two-hour postprandial.  Provided my name and number should there be additional dietary questions.
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DESCRIPTION: Dietary consultation for diabetes during pregnancy.

soap / chart / progress notes, diabetes during pregnancy, diabetes, insulin, gestational diabetes, adjusted for obesity, calorie requirements, dietary consultation, carbohydrate, postprandial, meal, calories, dietary, pregnancy, servings, snacks

This situation involves a pregnant woman with gestational diabetes, which is a medical condition that requires careful management to ensure the health of both the mother and the baby. There are risks associated with uncontrolled blood sugars during pregnancy, such as increased risk of complications for the mother and potential impacts on the fetal development. The healthcare professionals are actively managing her condition through dietary adjustments and insulin management. While it's not an immediate life-threatening situation, it is quite important to manage well to prevent complications. Therefore, the stakes are moderately high due to potential consequences if not managed properly.


Medical Specialty: Consult - History and Phy.
Sample Name: Tethered Cord Evaluation

REASON FOR VISIT: , The patient referred by Dr. X for evaluation of her possible tethered cord.,HISTORY OF PRESENT ILLNESS:,  Briefly, she is a 14-year-old right handed female who is in 9th grade, who underwent a lipomyomeningocele repair at 3 days of age and then again at 3-1/2 years of age.  The last surgery was in 03/95.  She did well; however, in the past several months has had some leg pain in both legs out laterally, worsening at night and requiring Advil, Motrin as well as Tylenol PM.,Denies any new bowel or bladder dysfunction or increased sensory loss.  She had some patchy sensory loss from L4 to S1.,MEDICATIONS: , Singulair for occasional asthma.,FINDINGS: , She is awake, alert, and oriented x 3.  Pupils equal and reactive.  EOMs are full.  Motor is 5 out of 5.  She was able to toe and heel walk without any difficulties as well as tendon reflexes were 2 plus.  There is no evidence of clonus.  There is diminished sensation from L4 to S1, having proprioception.,ASSESSMENT AND PLAN: , Possible tethered cord.  I had a thorough discussion with the patient and her parents.  I have recommended a repeat MRI scan.  The prescription was given today.  MRI of the lumbar spine was just completed.  I would like to see her back in clinic.  We did discuss the possible symptoms of this tethering.
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DESCRIPTION: Evaluation of possible tethered cord.  She underwent a lipomyomeningocele repair at 3 days of age and then again at 3-1/2 years of age.

consult - history and phy., tethering, lipomyomeningocele repair, sensory loss, tethered cord, mri, cord, lipomyomeningocele,

The situation involves the evaluation of a possible tethered cord in a 14-year-old, which could have significant implications for her neurological health if not appropriately diagnosed and treated. However, while important, it does not represent an immediate life-or-death scenario. The patient is currently stable, with an ongoing investigation via MRI planned, which suggests ongoing management rather than emergency intervention. This makes it a moderate-stakes situation in the context of medical evaluations.


Medical Specialty: Surgery
Sample Name: Mitral Valve Repair & Annuloplasty

OPERATIONS,1.  Mitral valve repair using a quadrangular resection of the P2 segment of the posterior leaflet.,2.  Mitral valve posterior annuloplasty using a Cosgrove Galloway Medtronic fuser band.,3.  Posterior leaflet abscess resection.,ANESTHESIA:  ,General endotracheal anesthesia,TIMES:  ,Aortic cross-clamp time was ** minutes.  Cardiopulmonary bypass time total was ** minutes.,PROCEDURE IN DETAIL: , After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room and general endotracheal anesthesia was administered.  Next, the patient's chest and legs were prepped and draped in standard surgical fashion.  A #10-blade scalpel was used to make a midline median sternotomy incision.  Dissection was carried down to the level of the sternum using Bovie electrocautery.  The sternum was opened with a sternal saw, and full-dose heparinization was given.  Next, the chest retractor was positioned.  The pericardium was opened with Bovie electrocautery and pericardial stay sutures were positioned.  We then prepared to place the patient on cardiopulmonary bypass.  A 2-0 Ethibond double pursestring was placed in the ascending aorta.  Through this was passed our aortic cannula and connected to the arterial side of the cardiopulmonary bypass machine.  Next, double cannulation with venous cannulas was instituted.  A 3-0 Prolene pursestring was placed in the right atrial appendage.  Through this was passed our SEC cannula.  This was connected to the venous portion of the cardiopulmonary bypass machine in a Y-shaped circuit.  Next, a 3-0 Prolene pursestring was placed in the lower border of the right atrium.  Through this was passed our inferior vena cava cannula.  This was likewise connected to the Y connection of our venous cannula portion.  We then used a 4-0 U-stitch in the right atrium for our retrograde cardioplegia catheter, which was inserted.  Cardiopulmonary bypass was instituted.  Metzenbaum scissors were used to dissect out the SVC and IVC, which were subsequently encircled with umbilical tape.  Sondergaard's groove was taken down.  Next, an antegrade cardioplegia needle and associated sump were placed in the ascending aorta.  This was connected appropriately as was the retrograde cardioplegia catheter.  Next, the aorta was cross-clamped, and antegrade and retrograde cardioplegia was infused so as to arrest the heart in diastole.  Next a #15-blade scalpel was used to open the left atrium.  The left atrium was decompressed with pump sucker.  Next, our self-retaining retractor was positioned so as to bring the mitral valve up into view.  Of note was the fact that the mitral valve P2 segment of the posterior leaflet had an abscess associated with it.  The borders of the P2 segment abscess were defined by using a right angle to define the chordae which were encircled with a 4-0 silk.  After doing so, the P2 segment of the posterior leaflet was excised with a #11-blade scalpel.  Given the laxity of the posterior leaflet, it was decided to reconstruct it with a 2-0 Ethibond pledgeted suture.  This was done so as to reconstruct the posterior annular portion.  Prior to doing so, care was taken to remove any debris and abscess-type material.  The pledgeted stitch was lowered into place and tied.  Next, the more anterior portion of the P2 segment was reconstructed by running a 4-0 Prolene stitch so as to reconstruct it.  This was done without difficulty.  The apposition of the anterior and posterior leaflet was confirmed by infusing solution into the left ventricle.  There was noted to be a small amount of central regurgitation.  It was felt that this would be corrected with our annuloplasty portion of the procedure.  Next, 2-0 non-pledgeted Ethibond sutures were placed in the posterior portion of the annulus from trigone to trigone in interrupted fashion.  Care was taken to go from trigone to trigone.  Prior to placing these sutures, the annulus was sized and noted to be a *** size for the Cosgrove-Galloway suture band ring from Medtronic.  After, as mentioned, we placed our interrupted sutures in the annulus, and they were passed through the CG suture band.  The suture band was lowered into position and tied in place.  We then tested our repair and noted that there was very mild regurgitation.  We subsequently removed our self-retaining retractor.  We closed our left atriotomy using 4-0 Prolene in a running fashion.  This was done without difficulty.  We de-aired the heart.  We then gave another round of antegrade and retrograde cardioplegia in warm fashion.  The aortic cross-clamp was removed, and the heart gradually resumed electromechanical activity.  We then removed our retrograde cardioplegia catheter from the coronary sinus and buttressed this site with a 5-0 Prolene.  We placed 2 ventricular and 2 atrial pacing leads which were brought out through the skin.  The patient was gradually weaned off cardiopulmonary bypass and our venous cannulas were removed.  We then gave full-dose protamine; and after noting that there was no evidence of a protamine reaction, we removed our aortic cannula.  This site was buttressed with a 4-0 Prolene on an SH needle.  The patient tolerated the procedure well.  We placed a mediastinal #32-French chest tube as well as a right chest Blake drain.  The mediastinum was inspected for any signs of bleeding.  There were none.  We closed the sternum with #7 sternal wires in interrupted figure-of-eight fashion.  The fascia was closed with a #1 Vicryl followed by a 2-0 Vicryl, followed by 3-0 Vicryl in a running subcuticular fashion.  The instrument and sponge count was correct at the end of the case.  The patient tolerated the procedure well and was transferred to the intensive care unit in good condition.
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DESCRIPTION: Mitral valve repair using a quadrangular resection of the P2 segment of the posterior leaflet.  Mitral valve posterior annuloplasty using a Cosgrove Galloway Medtronic fuser band.  Posterior leaflet abscess resection.

surgery, mitral valve repair, mitral valve, abscess resection, leaflet abscess, cosgrove galloway medtronic, bovie electrocautery, cannulation, bypass, annuloplasty, cardioplegia, mitral

This is a detailed description of a complex surgical procedure involving mitral valve repair and annuloplasty. Cardiothoracic surgeries, especially those involving the heart valves and cardiopulmonary bypass, are high-stakes due to the significant risks involved, including potential life-threatening complications. The need for cardioplegia to arrest the heart and the use of cardiopulmonary bypass highlight the technical and critical nature of such procedures. Additionally, any surgical intervention involving abscess resection further complicates the procedure. As such, the stakes are inherently high given the precision required, the vital nature of the organs involved, and the potential consequences of any errors.


Medical Specialty: Urology
Sample Name: Testicular Ultrasound

TESTICULAR ULTRASOUND,REASON FOR EXAM:  ,Left testicular swelling for one day.,FINDINGS:  ,The left testicle is normal in size and attenuation, it measures 3.2 x 1.7 x 2.3 cm.  The right epididymis measures up to 9 mm.  There is a hydrocele on the right side.  Normal flow is seen within the testicle and epididymis on the right.,The left testicle is normal in size and attenuation, it measures 3.9 x 2.1 x 2.6 cm.  The left testicle shows normal blood flow.  The left epididymis measures up to 9 mm and shows a markedly increased vascular flow.  There is mild scrotal wall thickening.  A hydrocele is seen on the left side.,IMPRESSION:,1.  Hypervascularity of the left epididymis compatible with left epididymitis.,2.  Bilateral hydroceles.
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DESCRIPTION: Left testicular swelling for one day.  Testicular Ultrasound.  Hypervascularity of the left epididymis compatible with left epididymitis.  Bilateral hydroceles.

urology, hypervascularity, bilateral hydroceles, epididymis, epididymitis, testicular ultrasound, ultrasound, flow, hydroceles, testicle, testicular,

The situation involves medical imaging findings from a testicular ultrasound. Testicular swelling and conditions such as epididymitis and hydroceles can cause discomfort and need medical attention, but they generally do not pose immediate life-threatening risks with prompt treatment. Epididymitis, if untreated, can lead to complications, but this is not a highly acute or high-stakes medical situation immediately. The medical assessment will guide appropriate treatment to prevent complications.


Medical Specialty: Bariatrics
Sample Name: Laparoscopic Gastric Bypass

PREOPERATIVE DIAGNOSIS: , Morbid obesity.,POSTOPERATIVE DIAGNOSIS:  ,Morbid obesity.,PROCEDURE: , Laparoscopic antecolic antegastric Roux-en-Y gastric bypass with EEA anastomosis.,ANESTHESIA: , General with endotracheal intubation.,INDICATION FOR PROCEDURE: , This is a 30-year-old female, who has been overweight for many years.  She has tried many different diets, but is unsuccessful.  She has been to our Bariatric Surgery Seminar, received some handouts, and signed the consent.  The risks and benefits of the procedure have been explained to the patient.,PROCEDURE IN DETAIL:  ,The patient was taken to the operating room and placed supine on the operating room table.  All pressure points were carefully padded.  She was given general anesthesia with endotracheal intubation.  SCD stockings were placed on both legs.  Foley catheter was placed for bladder decompression.  The abdomen was then prepped and draped in standard sterile surgical fashion.  Marcaine was then injected through umbilicus.  A small incision was made.  A Veress needle was introduced into the abdomen.  CO2 insufflation was done to a maximum pressure of 15 mmHg.  A 12-mm VersaStep port was placed through the umbilicus.  I then placed a 5-mm port just anterior to the midaxillary line and just subcostal on the right side.  I placed another 5-mm port in the midclavicular line just subcostal on the right side, a few centimeters below and medial to that, I placed a 12-mm VersaStep port.  On the left side, just anterior to the midaxillary line and just subcostal, I placed a 5-mm port.  A few centimeters below and medial to that, I placed a 15-mm port.  I began by lifting up the omentum and identifying the transverse colon and lifting that up and thereby identifying my ligament of Treitz.  I ran the small bowel down approximately 40 cm and divided the small bowel with a white load GIA stapler.  I then divided the mesentery all the way down to the base of the mesentery with a LigaSure device.  I then ran the distal bowel down, approximately 100 cm, and at 100 cm, I made a hole at the antimesenteric portion of the Roux limb and a hole in the antimesenteric portion of the duodenogastric limb, and I passed a 45 white load stapler and fired a stapler creating a side-to-side anastomosis.  I reapproximated the edges of the defect.  I lifted it up and stapled across it with another white load stapler.  I then closed the mesenteric defect with interrupted Surgidac sutures.  I divided the omentum all the way down to the colon in order to create a passageway for my small bowel to go antecolic.  I then put the patient in reverse Trendelenburg.  I placed a liver retractor, identified, and dissected the angle of His.  I then dissected on the lesser curve, approximately 2.5 cm below the gastroesophageal junction, and got into a lesser space.  I fired transversely across the stomach with a 45 blue load stapler.  I then used two fires of the 60 blue load with SeamGuard to go up into my angle of His, thereby creating my gastric pouch.  I then made a hole at the base of the gastric pouch and had Anesthesia remove the bougie and place the OG tube connected to the anvil.  I pulled the anvil into place, and I then opened up my 15-mm port site and passed my EEA stapler.  I passed that in the end of my Roux limb and had the spike come out antimesenteric.  I joined the spike with the anvil and fired a stapler creating an end-to-side anastomosis, then divided across the redundant portion of my Roux limb with a white load GI stapler, and removed it with an Endocatch bag.  I put some additional 2-0 Vicryl sutures in the anastomosis for further security.  I then placed a bowel clamp across the bowel.  I went above and passed an EGD scope into the mouth down to the esophagus and into the gastric pouch.  I distended gastric pouch with air.  There was no air leak seen.  I could pass the scope easily through the anastomosis.  There was no bleeding seen through the scope.  We closed the 15-mm port site with interrupted 0 Vicryl suture utilizing Carter-Thomason.  I copiously irrigated out that incision with about 2 L of saline.  I then closed the skin of all incisions with running Monocryl.  Sponge, instrument, and needle counts were correct at the end of the case.  The patient tolerated the procedure well without any complications.
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DESCRIPTION: Morbid obesity.  Laparoscopic antecolic antegastric Roux-en-Y gastric bypass with EEA anastomosis.  This is a 30-year-old female, who has been overweight for many years.  She has tried many different diets, but is unsuccessful.

bariatrics, gastric bypass, eea anastomosis, roux-en-y, antegastric, antecolic, morbid obesity, roux limb, gastric pouch, intubation, laparoscopic, bypass, roux, endotracheal, anastomosis, gastric

The situation described involves a laparoscopic gastric bypass surgery, which is a significant procedure with inherent risks and potential complications. It is used to treat morbid obesity when other weight-loss approaches have failed. The stakes are high because the surgery involves multiple steps, requires general anesthesia, and has a direct impact on the patient's long-term health and quality of life. Complications can include bleeding, infection, blood clots, gastrointestinal leaks, and long-term nutritional deficiencies. The patient's safety during and after the procedure is critical, making it a high-stakes situation.


Medical Specialty: Radiology
Sample Name: EMG/Nerve Conduction Study

HISTORY:,  The patient is a 52-year-old female with a past medical history of diet-controlled diabetes, diffuse arthritis, plantar fasciitis, and muscle cramps who presents with a few-month history of numbness in both big toes and up the lateral aspect of both calves.  Symptoms worsened considerable about a month ago.  This normally occurs after being on her feet for any length of time.  She was started on amitriptyline and this has significantly improved her symptoms.  She is almost asymptomatic at present.  She dose complain of longstanding low back pain, but no pain that radiates from her back into her legs.  She has had no associated weakness.,On brief examination, straight leg raising is normal.  The patient is obese.  There is mild decreased vibration and light touch in distal lower extremities.  Strength is full and symmetric.  Deep tendon reflexes at the knees are 2+ and symmetric and absent at the ankles.,NERVE CONDUCTION STUDIES: , Bilateral sural sensory responses are absent.  Bilateral superficial sensory responses are present, but mildly reduced.  The right radial sensory response is normal.  The right common peroneal and tibial motor responses are normal.  Bilateral H-reflexes are absent.,NEEDLE EMG:,  Needle EMG was performed on the right leg and lumbosacral paraspinal muscles and the left tibialis posterior using a concentric disposable needle.  It revealed increased insertional activity in the right tibialis posterior muscle with signs of mild chronic denervation in bilateral peroneus longus muscles and the right tibialis posterior muscle.  Lumbar paraspinals were attempted, but were too painful to get a good assessment.,IMPRESSION:  ,This electrical study is abnormal.  It reveals the following:,1.  A very mild, purely sensory length-dependent peripheral neuropathy.,2.  Mild bilateral L5 nerve root irritation.  There is no evidence of active radiculopathy.,Based on the patient's history and exam, her new symptoms are consistent with mild bilateral L5 radiculopathies.  Symptoms have almost completely resolved over the last month since starting Elavil.  I would recommend MRI of the lumbosacral spine if symptoms return.  With respect to the mild neuropathy, this is probably related to her mild glucose intolerance/early diabetes.  However, I would recommend a workup for other causes to include the following:  Fasting blood sugar, HbA1c, ESR, RPR, TSH, B12, serum protein electrophoresis and Lyme titer.
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DESCRIPTION: History of numbness in both big toes and up the lateral aspect of both calves.  She dose complain of longstanding low back pain, but no pain that radiates from her back into her legs.  She has had no associated weakness.

radiology, nerve conduction studies, needle emg, numbness, tibialis posterior muscle, sensory responses, muscle, tibialis, toes

The situation involves a radiology assessment to understand neuropathy and radiculopathy in a patient with mild glucose intolerance. While the patient's symptoms have largely resolved and no immediate severe issue is identified, it involves assessing potential underlying causes which could influence future health significantly. The stakes are moderate because it involves uncovering potential causes for neuropathy which, if left untreated, could lead to more severe health issues, particularly in a patient with early signs of diabetes. However, there is no immediate life-threatening condition based on the current report.


Medical Specialty: Radiology
Sample Name: Coronary CT Angiography (CCTA) - 1

HISTORY: , Coronary artery disease.,TECHNIQUE AND FINDINGS:  ,Calcium scoring and coronary artery CTA with cardiac function was performed on Siemens dual-source CT scanner with postprocessing on Vitrea workstation.  Patient received oral Metoprolol 100 milligrams.  100 ml Ultravist 370 was utilized as the contrast agent.  0.4 milligrams of nitroglycerin was given.,Patient's calcium score 164, volume 205; this places the patient between the 75th and 90th percentile for age.  There is at least moderate atherosclerotic plaque with mild coronary artery disease and significant narrowings possible.,Cardiac wall motion was within normal limits.  Left ventricular ejection fraction calculated to be 82%.  End-diastolic volume 98 mL, end-systolic volume calculated to be 18 mL.,There is normal coronary artery origins.  There is codominance between the right coronary artery and the circumflex artery.  There is mild to moderate stenosis of the proximal LAD with mixed plaque.  Mild stenosis mid LAD with mixed plaque.  No stenosis.  Distal LAD with the distal vessel becoming diminutive in size.  Right coronary artery shows mild stenosis proximally and in the midportion due to calcified focal plaque.  Once again the distal vessel becomes diminutive in size.  Circumflex shows mild stenosis due to focal calcified plaque proximally.  No stenosis is seen involving the mid or distal circumflex.  The distal circumflex also becomes diminutive in size.  The left main shows small amount of focal calcified plaque without stenosis.  Myocardium, pericardium and wall motion was unremarkable as seen.,IMPRESSION:,1.  Atherosclerotic coronary artery disease with values as above.  There are areas of stenosis most pronounced in the LAD with mild to moderate change and mild stenosis involving the circumflex and right coronary artery.,2.  Consider cardiology consult and further evaluation if clinically indicated.,3.  Full report was sent to the PACS.  Report will be mailed to Dr. ABC.
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DESCRIPTION: CCTA with cardiac function and calcium scoring.

radiology, coronary ct angiography, vitrea workstation, cardiac wall motion, proximal lad, distal lad, focal calcified plaque, coronary artery disease, cardiac function, calcium scoring, wall motion, distal vessel, calcified plaque, distal circumflex, artery disease, mild stenosis, coronary artery, ccta, scoring, atherosclerotic, vessel, calcium, calcified, lad, circumflex, distal, plaque, coronary, artery, stenosis,

The report indicates the presence of coronary artery disease with atherosclerotic plaque and some stenosis, predominantly in the LAD (Left Anterior Descending artery) which is a major coronary artery. While the condition is identified as mild to moderate and is stable at this moment, coronary artery disease can progression and potentially lead to serious cardiovascular events like a heart attack if not monitored or managed. However, the current findings do not specify any immediate life-threatening conditions, but recommend further evaluation. The context suggests a moderate level of stakes, given the potential for future heart events.


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

Medical Specialty: Neurology
Sample Name: Temporal Artery Biopsy

PREOPERATIVE DIAGNOSIS:,  Rule out temporal arteritis.,POSTOPERATIVE DIAGNOSIS:  ,Rule out temporal arteritis.,PROCEDURE:,  Bilateral temporal artery biopsy.,ANESTHESIA:,  Local anesthesia 1% Xylocaine with epinephrine.,INDICATIONS:,  I was consulted by Dr. X for this patient with bilateral temporal headaches to rule out temporal arteritis.  I explained fully the procedure to the patient.,PROCEDURE: , Both sides were done exactly the same way.  After 1% Xylocaine infiltration, a 2 to 3-cm incision was made over the temporal artery.  The temporal artery was identified and was grossly normal on both sides.  Proximal and distal were ligated with both of 3-0 silk suture and Hemoccult.  The specimen of temporal artery was taken from both sides measuring at least 2 to 3 cm.  They were sent as separate specimens, right and left labeled.  The wound was then closed with interrupted 3-0 Monocryl subcuticular sutures and Dermabond.  She tolerated the procedure well.
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DESCRIPTION: Bilateral temporal artery biopsy.  Rule out temporal arteritis.

neurology, headaches, bilateral temporal artery, temporal artery biopsy, temporal arteritis, temporal artery, temporal, biopsy, arteritis

The procedure described is a temporal artery biopsy to rule out temporal arteritis, a condition that could lead to serious complications like vision loss if not diagnosed and managed properly. However, the procedure itself, conducted under local anesthesia, is routine and not inherently high-risk. It is common in medical diagnostic practice. The potential seriousness of untreated temporal arteritis increases the stakes slightly, but the procedure is straightforward.


Medical Specialty: IME-QME-Work Comp etc.
Sample Name: Occupational Medicine Consult - 1

ALLOWED CONDITIONS:,  Left knee strain, meniscus tear left knee.,CONTESTED CONDITION:,  Osteoarthritis of the left knee.,EMPLOYER:,  ABCD.,I examined Xxxxx today September 14, 2007, for the above allowed conditions and also the contested condition of osteoarthritis of his left knee.  He is a 57-year-old assembly worker who was injured on June 13, 2007, which according to his FROI was due to "repairing cars, down on knees to work on concrete floors."  In addition, he slipped on an air hose on the floor at work on March 7, 2007, re-injuring his left knee.  He developed pain and swelling in his left knee.  He denies having any difficulties with his left knee prior to the injury of June 13, 2002.,DIAGNOSTIC STUDIES: , August 2, 2002, MRI of the left knee showed low-grade chondromalacia of the left patellofemoral joint space and a posterior horn tear of the medial meniscus, likely degenerative in nature, and also grade II to III chondromalacia of the medial joint space.  On June 26, 2007, MRI of his left knee was referred to in the injury management report of June 19, 2007, as showing osteoarthritis of the medial compartment has advanced.  He brought with him copies of x-rays taken July 16, 2007, of his left knee, which I reviewed and which showed marked narrowing of the medial compartment of his left knee with spurs on the margins of the joint medially and also spurs on the patella.  There was subluxation of the tibia on the femur with standing.,After his injury, he received treatment from Dr. X for patellofemoral syndrome with knee sleeve.  He also received treatment from Dr. Y also for left knee sprain and patellar pain.  He also did exercise, does use a knee sleeve and Aleve.  On December 5, 2002, he underwent arthroscopy of the left knee by Dr. Z who did a partial resection of a torn medial meniscus.  He also noticed grade III chondromalacia of the patella as well as the torn medial meniscus.  He states that he was asymptomatic until he slipped on an air hose while at work on March 7, 2007, and again developed pain and swelling in his left knee.  Standing aggravates his pain.  He has had one injection of cortisone by Dr. Z about a month ago, which has helped his pain.  He takes one hydrocodone 7.5/750 mg daily.,Examination of his left knee revealed there was bilateral varus deformity, healed arthroscopy incisional scars, there was a 1/2 atrophy of the left calf.  There was patellar crepitus with knee motion.  There was no motor weakness or reflex changes.  He walked without a limp and could stand on his heels and toes equally well.  There was no instability of the knee and no effusion.  Range of motion was 0 to 120 degrees.,QUESTION: , Xxxxx has recently filed to reactivate this claim.  Please give me your opinion as to whether Xxxxx's current clinical presentation is related to the industrial injury stated above.,ANSWER:, Yes.  His original MRI of August 2, 2002, did show low-grade chondromalacia of the patellofemoral joint and also grade II to III chondromalacia of the medial joint space, which was the beginning of osteoarthritis.  Also, it is well known that torn medial meniscus can result in osteoarthritis of the knee; therefore, the osteoarthritis is related to his original injury of June 13, 2007, specifically to the torn medial meniscus.,QUESTION:  ,Do I believe that claim #123 should be reactivated to allow for treatment of the allowed conditions as stated?,ANSWER:, Yes, I believe it should be reactivated to allow treatment of the contested condition of osteoarthritis of his left knee.,QUESTION:,  Xxxxx has filed an application for additional allowance of osteoarthritis of the left knee.  Based on the current objective findings, mechanism of injury, medical records, and diagnostic studies, does the medical evidence support the existence of the requested condition?,ANSWER: ,Yes.  Please see the discussion in the answer to question no one.  In addition, x-rays of July 16, 2007, do reveal medial compartment and patellofemoral compartment osteoarthritis of the left knee.,QUESTION: , If you find this condition exists, is it a direct and proximate result of the June 13, 2002, injury?,ANSWER:, Yes.  See discussion in answer to question number one.,QUESTION: , Do you find that Xxxxx's injury or disability was caused by the natural deterioration of tissue, an organ or part of body?,ANSWER: ,No.  I believe the osteoarthritis was the result of the torn medial meniscus as discussed under question number one.,QUESTION: , In addition, if you find the condition exists, are there non-occupational activities or intervening injuries, which could have contributed to Xxxxx's condition?,ANSWER:, No.  He does not give any history of any intervening injuries.,If you opine the requested condition should be additionally recognized, please include the condition as an allowed condition in the discussion of the following questions.,QUESTION:,  Based on the objective findings is the request for 10 sessions of physical therapy per C-9 dated July 27, 2007, medically necessary and appropriate for the allowed conditions of the claim of osteoarthritis of left knee?,ANSWER:,  Yes.,
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DESCRIPTION: Occupational medicine consult with questions-answers.

The situation involves a worker's compensation claim and the medical evaluation of a knee condition potentially linked to a workplace injury. The evaluation's outcome can impact whether the worker receives necessary medical treatment and financial support for their injury. Since this has both financial and health impacts for the patient, it is moderately high-stakes. However, it is not life-threatening or critical care, which would make it extremely high-stakes.


Medical Specialty: Surgery
Sample Name: Pigtail Catheter Insertion

PREOPERATIVE DIAGNOSIS:  ,Left hemothorax, rule out empyema.,POSTOPERATIVE DIAGNOSIS: , Left hemothorax rule out empyema.,PROCEDURE: , Insertion of a 12-French pigtail catheter in the left pleural space.,PROCEDURE DETAIL:  ,After obtaining informed consent, the patient was taken to the minor OR in the Same Day Surgery where his posterior left chest was prepped and draped in a usual fashion.  Xylocaine 1% was injected and then a 12-French pigtail catheter was inserted in the medial scapular line about the eighth intercostal space.  It was difficult to draw fluid by syringe, but we connected the system to a plastic bag and by gravity started draining at least 400 mL while we were in the minor OR.  Samples were sent for culture and sensitivity, aerobic and anaerobic.,The patient and I decided to admit him for a period of observation at least overnight.,He tolerated the procedure well and the postprocedure chest x-ray showed no complications.
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DESCRIPTION: Left hemothorax, rule out empyema.  Insertion of a 12-French pigtail catheter in the left pleural space.

surgery, chest, pleural space, pigtail catheter, insertion, empyema, hemothorax,

The insertion of a pigtail catheter is a medical procedure with moderate risk due to the potential for complications such as infection, bleeding, or organ injury. The stakes are elevated due to the diagnosis of a left hemothorax, which is a serious condition as it involves the accumulation of blood in the pleural space and carrying the potential complication of empyema. The procedure successfully drained 400 mL of fluid and samples were sent for analysis, reducing immediate risks. Additionally, the patient was admitted for observation, suggesting the presence of ongoing risks that need monitoring.


Medical Specialty: Discharge Summary
Sample Name: Discharge Summary - 6

DISCHARGE DATE:  MM/DD/YYYY,HISTORY OF PRESENT ILLNESS:  Mr. ABC is a 60-year-old white male veteran with multiple comorbidities, who has a history of bladder cancer diagnosed approximately two years ago by the VA Hospital.  He underwent a resection there.  He was to be admitted to the Day Hospital for cystectomy.  He was seen in Urology Clinic and Radiology Clinic on MM/DD/YYYY.,HOSPITAL COURSE:  Mr. ABC presented to the Day Hospital in anticipation for Urology surgery.  On evaluation, EKG, echocardiogram was abnormal, a Cardiology consult was obtained.  A cardiac adenosine stress MRI was then proceeded, same was positive for inducible ischemia, mild-to-moderate inferolateral subendocardial infarction with peri-infarct ischemia.  In addition, inducible ischemia seen in the inferior lateral septum.  Mr. ABC underwent a left heart catheterization, which revealed two vessel coronary artery disease.  The RCA, proximal was 95% stenosed and the distal 80% stenosed.  The mid LAD was 85% stenosed and the distal LAD was 85% stenosed.  There was four Multi-Link Vision bare metal stents placed to decrease all four lesions to 0%.  Following intervention, Mr. ABC was admitted to 7 Ardmore Tower under Cardiology Service under the direction of Dr. XYZ.  Mr. ABC had a noncomplicated post-intervention hospital course.  He was stable for discharge home on MM/DD/YYYY with instructions to take Plavix daily for one month and Urology is aware of the same.,DISCHARGE EXAM:,VITAL SIGNS:  Temperature 97.4, heart rate 68, respirations 18, blood pressure 133/70.,HEART:  Regular rate and rhythm.,LUNGS:  Clear to auscultation.,ABDOMEN:  Obese, soft, nontender.  Lower abdomen tender when touched due to bladder cancer.,RIGHT GROIN:  Dry and intact, no bruit, no ecchymosis, no hematoma.  Distal pulses are intact.,DISCHARGE LABS:  CBC:  White count 5.4, hemoglobin 10.3, hematocrit 30, platelet count 132, hemoglobin A1c 9.1.  BMP:  Sodium 142, potassium 4.4, BUN 13, creatinine 1.1, glucose 211.  Lipid profile:  Cholesterol 157, triglycerides 146, HDL 22, LDL 106.,PROCEDURES:,1.  On MM/DD/YYYY, cardiac MRI adenosine stress.,2.  On MM/DD/YYYY, left heart catheterization, coronary angiogram, left ventriculogram, coronary angioplasty with four Multi-Link Vision bare metal stents, two placed to the LAD in two placed to the RCA.,DISCHARGE INSTRUCTIONS:  Mr. ABC is discharged home.  He should follow a low-fat, low-salt, low-cholesterol, and heart healthy diabetic diet.  He should follow post-coronary artery intervention restrictions.  He should not lift greater than 10 pounds for seven days.  He should not drive for two days.  He should not immerse in water for two weeks.  Groin site care reviewed with patient prior to being discharged home.  He should check groin for bleeding, edema, and signs of infection.  Mr. ABC is to see his primary care physician within one to two weeks, return to Dr. XYZ's clinic in four to six weeks, appointment card to be mailed him.  He is to follow up with Urology in their clinic on MM/DD/YYYY at 10 o'clock and then to scheduled CT scan at that time.,DISCHARGE DIAGNOSES:,1.  Coronary artery disease status post percutaneous coronary artery intervention to the right coronary artery and to the LAD.,2.  Bladder cancer.,3.  Diabetes.,4.  Dyslipidemia.,5.  Hypertension.,6.  Carotid artery stenosis, status post right carotid endarterectomy in 2004.,7.  Multiple resections of the bladder tumor.,8.  Distant history of appendectomy.,9.  Distant history of ankle surgery.
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DESCRIPTION: A white male veteran with multiple comorbidities, who has a history of bladder cancer diagnosed approximately two years ago by the VA Hospital.

discharge summary, coronary artery disease, heart catheterization, artery disease, bare metal, metal stents, artery intervention, bladder cancer, coronary artery, veteran, surgery, cardiac, inducible, catheterization, ischemia, cancer, urology, stenosed, bladder, heart, artery, coronary,

The discharge summary details a complex medical situation involving multiple comorbidities, a recent cardiac procedure, and ongoing management of cancer requiring coordination of care among multiple specialists. The patient's stable discharge after successful cardiac intervention is encouraging, but the follow-up care instructions are critical to prevent complications such as bleeding at the catheterization site. Given the serious nature of the conditions involved (coronary artery disease, bladder cancer), the risk of complications, and the need for careful follow-up, this discharge summary represents a moderately high-stakes situation.


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

HISTORY:,  The patient is a 52-year-old female with a past medical history of diet-controlled diabetes, diffuse arthritis, plantar fasciitis, and muscle cramps who presents with a few-month history of numbness in both big toes and up the lateral aspect of both calves.  Symptoms worsened considerable about a month ago.  This normally occurs after being on her feet for any length of time.  She was started on amitriptyline and this has significantly improved her symptoms.  She is almost asymptomatic at present.  She dose complain of longstanding low back pain, but no pain that radiates from her back into her legs.  She has had no associated weakness.,On brief examination, straight leg raising is normal.  The patient is obese.  There is mild decreased vibration and light touch in distal lower extremities.  Strength is full and symmetric.  Deep tendon reflexes at the knees are 2+ and symmetric and absent at the ankles.,NERVE CONDUCTION STUDIES: , Bilateral sural sensory responses are absent.  Bilateral superficial sensory responses are present, but mildly reduced.  The right radial sensory response is normal.  The right common peroneal and tibial motor responses are normal.  Bilateral H-reflexes are absent.,NEEDLE EMG:,  Needle EMG was performed on the right leg and lumbosacral paraspinal muscles and the left tibialis posterior using a concentric disposable needle.  It revealed increased insertional activity in the right tibialis posterior muscle with signs of mild chronic denervation in bilateral peroneus longus muscles and the right tibialis posterior muscle.  Lumbar paraspinals were attempted, but were too painful to get a good assessment.,IMPRESSION:  ,This electrical study is abnormal.  It reveals the following:,1.  A very mild, purely sensory length-dependent peripheral neuropathy.,2.  Mild bilateral L5 nerve root irritation.  There is no evidence of active radiculopathy.,Based on the patient's history and exam, her new symptoms are consistent with mild bilateral L5 radiculopathies.  Symptoms have almost completely resolved over the last month since starting Elavil.  I would recommend MRI of the lumbosacral spine if symptoms return.  With respect to the mild neuropathy, this is probably related to her mild glucose intolerance/early diabetes.  However, I would recommend a workup for other causes to include the following:  Fasting blood sugar, HbA1c, ESR, RPR, TSH, B12, serum protein electrophoresis and Lyme titer.
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DESCRIPTION: History of numbness in both big toes and up the lateral aspect of both calves.  She dose complain of longstanding low back pain, but no pain that radiates from her back into her legs.  She has had no associated weakness.

physical medicine - rehab, nerve conduction studies, needle emg, numbness, tibialis posterior muscle, sensory responses, muscle, tibialis, toes

The situation involves a medical procedure and diagnosis related to nerve conduction and EMG tests, which can be important for determining the underlying causes of nerve-related symptoms. However, the patient's condition seems stable or improving with medication, and there are no immediate life-threatening issues identified, such as active radiculopathy or severe nerve damage. The recommendation for an MRI is conditional based on symptom recurrence, suggesting a moderate, not immediate critical, level of concern. Therefore, while the situation requires attention, it is not extremely high-stakes as it stands.


Medical Specialty: Radiology
Sample Name: Arachnoid Cyst

CC:, Seizures.,HX: ,The patient was initially evaluated at UIHC at 7 years of age. He had been well until 7 months prior to evaluation when he started having spells which were described as "dizzy spells" lasting from several seconds to one minute in duration. They occurred quite infrequently and he was able to resume activity immediately following the episodes. The spell became more frequent and prolonged, and by the time of initial evaluation were occurring 2-3 times per day and lasting 2-3 minutes in duration. In addition, in the 3 months prior to evaluation, the right upper extremity would become tonic and flexed during the episodes, and he began to experience post ictal fatigue.,BIRTH HX:, 32 weeks gestation to a G4 mother and weighed 4#11oz. He was placed in an incubator for 3 weeks. He was jaundiced, but there was no report that he required treatment.,PMH: ,Single febrile convulsion lasting "3 hours" at age 2 years.,MEDS: ,none.,EXAM:, Appears healthy and in no acute distress. Unremarkable general and neurologic exam.,Impression: Psychomotor seizures.,Studies: Skull X-Rays were unremarkable.,EEG showed "minimal spike activity during hyperventilation, as well as random sharp delta activity over the left temporal area, in drowsiness and sleep. This record also showed moderate amplitude asymmetry ( left greater than right) over the frontal central and temporal areas, which is a peculiar finding.",COURSE:, The patient was initially treated with Phenobarbital; then Dilantin was added (early 1970's); then Depakene was added ( early 1980's) due to poor seizure control. An EEG on 8/22/66 showed "Left mid-temporal spike focus with surrounding slow abnormality, especially posterior to the anterior temporal areas (sparing the parasagittal region). In addition, the right lateral anterior hemisphere voltage is relatively depressed. ...this suggests two separate areas of cerebral pathology." He underwent his first HCT scan in Sioux City in 1981, and this revealed an right temporal arachnoid cyst. The patient had behavioral problems throughout elementary/junior high/high school. He underwent several neurosurgical evaluations at UIHC and Mayo Clinic and was told that surgery was unwarranted. He was placed on numerous antiepileptic medication combinations including Tegretol, Dilantin, Phenobarbital, Depakote, Acetazolamide, and Mysoline. Despite this he averaged 2-3 spells a month. He was last seen, 6/19/95, and was taking Dilantin and Tegretol. His typical spells were described as sudden in onset and without aura. He frequently becomes tonic or undergoes tonic-clonic movement and falls with associated loss of consciousness. He usually has rapid recovery and can return to work in 20 minutes. He works at a Turkey packing plant. Serial HCT scans showed growth in the arachnoid cyst until 1991, when growth arrest appeared to have occurred.
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DESCRIPTION: CT Brain - arachnoid cyst Arachnoid cyst diagnosed by CT brain.

radiology, arachnoid cyst, hct scan, seizures, serial hct scans, dizzy spells, drowsiness, hyperventilation, loss of consciousness, moderate amplitude asymmetry, temporal area, tonic-clonic movement, phenobarbital, dilantin, cyst, temporal, arachnoid

The situation involves a patient with a complex medical history of seizures linked to an arachnoid cyst, who has undergone numerous evaluations and medication trials without successful control of the seizures. Despite this, surgical intervention was deemed unwarranted. The patient's condition impacts his daily life and work, given the frequent seizures and the need for recovery time. This medical case has implications on the patient’s quality of life, overall health, and ability to perform his job safely, highlighting the high-stakes nature of managing such a chronic and complex condition. Thus, it requires careful and informed decision-making by medical professionals to prevent adverse outcomes.


Medical Specialty: Psychiatry / Psychology
Sample Name: Psych Consult - Assaultive Behavior

IDENTIFYING DATA:  ,The patient is a 40-year-old white male.  He is married, on medical leave from his job as a tree cutter, and lives with his wife and five children.,CHIEF COMPLAINT AND REACTION TO HOSPITALIZATION:  ,The patient is admitted on a 72-hour involuntary treatment for dangerousness to others after repeated assaultive behaviors at Hospital Emergency Room, the morning prior to admission.,HISTORY OF PRESENT ILLNESS:  ,The patient was very sleepy this morning, only minimally cooperative with interview.  Additional information taken from the emergency room records that accompanied him from Hospital yesterday as well as from his wife, who I contacted by telephone.  The patient was apparently at his stable baseline when discharged from the Hospital on 01/21/10, status post back surgery following a work-related injury.  The patient returned to Emergency Room on the evening prior to admission complaining of severe back pain.  His ER course is notable for yelling, spitting, and striking multiple staff members.  The patient was originally to be admitted for pain control, but when he threatened to leave, he was referred to MHPs, who subsequently detained him for 72 hours for dangerousness to others.  On interview, the patient reports only hazy memories of these incidences and states this behavior was secondary to his pain and his medications.  He was contrite about the violence.  When his wife was contacted by telephone, she agreed with this assessment and reports that he has a history of domestic violence usually in the setting of alcohol and illicit substance intoxication, but denies any events in the last 3 years.,His wife reports that after discharge from the hospital, on 01/21/10, he was prescribed Percocet, Soma, hydroxyzine, and Valium.  He essentially exhausted his approximately 10 days' supply of these agents on the morning of 01/23/10, and as above believes that this was responsible for his presentation yesterday.  She reports that she has been in contact with him since his arrival in our facility and reports that he is "back to normal." She denies feeling that he currently represents a threat to her or her five children.  She was unaware of his mental health history, but denies that he has received care for any condition since they were married three years ago.,PAST PSYCHIATRIC HISTORY: , The patient has a history of Involuntary Treatment Act of 72 hours in our facility in 2004 or 2005 for assaultive behaviors; however, these records are not currently available for review.  The patient denies any outpatient mental health treatment before or since this hospitalization.  He describes his mental health diagnosis of bipolar affective disorder; however, he denies a history of dramatic mood swings in the absence of illicit substances or alcohol intoxication.,PAST MEDICAL HISTORY:,  Notable for status post back surgery, discharged from Hospital on 01/21/10.,MEDICATIONS:,  From discharge from Hospital on 01/21/10, include Percocet, Valium, Soma, and Vistaril, doses and frequency are not currently known.  His wife reports that he was discharged with approximately 10 days' supply of these agents.,SOCIAL AND DEVELOPMENTAL HISTORY:  ,The patient is employed as a tree cutter, currently on medical leave for the last 2 months following a back injury.  He lives with his wife and children.  He has a history of domestic violence, but not recently.  Other details of occupational, educational history not currently known.,SUBSTANCE AND ALCOHOL HISTORY:,  Records indicate a previous history of methamphetamine and alcohol abuse/dependence.  The wife states that he has not consumed either since 12/07.  Of note, urine tox screen at Hospital was positive for marijuana.,LEGAL HISTORY:  ,The patient has been charged with domestic violence in the past, but his wife denies any repeat instances since in the last 3 years.  It is not known whether the patient is currently on probation.,GENETIC PSYCHIATRIC HISTORY: , Unknown.,MENTAL STATUS EXAMINATION:,Attitude:  The patient is only minimally cooperative with interview secondary to being sleepy, and after repeated attempts to ask questions, he rolled over and went to bed.,Appearance: He is unkempt and there are multiple visible tattoos on his biceps.,Psychomotor:  There is no obvious psychomotor agitation or retardation.  There are no obvious extrapyramidal symptoms of tardive dyskinesia.,Affect:  His affect is notably restricted probably due to the fact that he is sleepy.,Mood:  Describes his mood as "okay.",Speech:  Speech is normal rate, volume, and tone.,Thought Processes:  His thought processes appear to be linear.,Thought Content:  His thought content is notable for his expressions of contrition about violence at Hospital last night.  He denies suicidal or homicidal ideation.,Cognitive Assessment:  Cognitively, he is alert and oriented to person, place, and date but not situation.  Attributes this to not really remembering the events at Hospital that resulted in this hospitalization.,Judgment and Insight:  His insight and judgment are both appear to be improving.,Assets:  Include his supportive wife and the fact he has been able to remain alcohol and methamphetamine sobriety for the last 3 years.,Limitations:  Include his back injury and possible need for improvement of health treatment engagement.,FORMULATION:  ,This is a 40-year-old white male, who was admitted for an acute agitation in the setting of misuse of prescribed opiates, Soma, hydroxyzine, and Valium.  He appears much improved from his condition at Hospital last night and I suspect that his behavior is most likely attributed to delirium and this since resolved.  He reports historical diagnosis of bipolar affective disorder, however, the details of this diagnosis are not currently available for review.,DIAGNOSES:,AXIS I:  Delirium, resolved (recent mental status changes likely secondary to misuse of prescribed opiates, Soma, Valium, and hydroxyzine.)  Rule out bipolar affective disorder.,AXIS II:  Deferred.,AXIS III:  Chronic pain status post back surgery.,AXIS IV:  Appears to be moderate.  He is currently on medical leave from his job.,AXIS V:  Global Assessment of Functioning is currently 50 (his GAF was 20 approximately 24 hours ago).,ESTIMATED LENGTH OF STAY:,  Three days.,PLAN:,  I will hold psychiatric medications for now given the patient's fairly rapid improvement as he cleared from the condition, I suspect is likely due to misuse of prescribed medications.  The patient will be placed on CIWA protocol given that one of the medications he overused was Valium.  Of note, he does not currently appear to be withdrawing and I anticipate that his CIWA will be discontinued prior to discharge.  I would like to increase the database regarding the details of his historical diagnosis of bipolar affective disorder before pursuing referrals for outpatient mental health care.  The internal medicine service will evaluate for treatment for any underlying medical problems specifically to provide recommendations regarding pain management.
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DESCRIPTION: The patient is admitted on a 72-hour involuntary treatment for dangerousness to others after repeated assaultive behaviors at Hospital Emergency Room, the morning prior to admission.

The situation involves a patient who was admitted for dangerous behavior following misuse of prescribed medications, which led to assaultive behavior. He has a history of domestic violence and substance abuse, although reportedly not in the past three years. The high-stakes elements here include the immediate risk he posed to hospital staff and possibly his family, which necessitated involuntary treatment. However, his condition seems to have stabilized and improved quickly, and his family's assessment of his threat level has been downgraded. The stakes are high due to the potential for future violence, the need for further assessment of his psychiatric and substance use history, and the management of his pain medication post-surgery.


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

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

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

Anterior cervical discectomy and fusion is a significant surgical procedure, particularly given its nature involving the spinal region. The potential risks outlined, such as infection, hemorrhage, neurologic deficits, and complications with anesthesia, highlight the high-stakes nature inherent in the procedure. Additionally, the outcome of the surgery could crucially impact the patient's quality of life, further emphasizing its importance. Spinal surgeries generally involve meticulous planning and precision due to the critical functions affected.