Medical Specialty: Psychiatry / Psychology
Sample Name: Pseudoseizures

REASON FOR REFERRAL: , The patient was referred to me by Dr. X of the Hospitalist Service at Children's Hospital due to a recent admission for pseudoseizures.  This was a 90-minute initial intake completed on 10/19/2007 with the patient's mother.  I have reviewed with her the boundaries of confidentiality and the treatment consent form, and she stated that she had understood these concepts.,PRESENTING PROBLEM: , It is reported that the patient was recently hospitalized and has been hospitalized in 2 occasions for pseudoseizure activity.  These were confirmed by video EEG and consist of trembling, shaking, and things of that nature.  She does have a history of focal seizures and perhaps simple seizures, which were diagnosed when she was 5 years old, but the seizure activity that was documented during the hospital stay is of a significant different quality.  I had met with them in the hospital and introduced myself and gathered some basic background information, but this is a supplement to that information, which is contained within this chart.  It was reported to me that she has been under considerable stress.  First of all, it should be noted that the patient is developmentally delayed.  Although she is 17 years old, she operates at about a fourth grade level.  Mother reported that The patient becomes stressed because she thinks that everyone is against her, that she cannot do anything unless someone is there, that she needs a lot of direction, that she gets confused easily, that she thinks that people become angry at her, that she misinterprets what people are saying and thinks that they are upset.  It is reported, the patient feels that her mother yells at her, and that is mad at her often.  It was reported that in addition she recently has had change in her visitation with her father, that she within the last 6 months, has started seeing her father every other weekend after he had been discharged from prison.  She reported that what is stress for her is that sometimes he does not always show up for visits or is late and that upsets her a lot and that she is upset when she has to leave him, also additional stressor is at school.  She reports that she has no friends that she feels unwanted and picked on.  She gets confused easily at school, worries about things, and believes that the teachers become angry with her.  In regards to her mood, mother reported that she is usually happy, unless things do not go her way, and then, she becomes upset and says that nobody cares about her.  She sits in the couch, she become angry, does not speak.  Mother sends her to her room, and she calms down, takes a couple of deep breaths, and that passes.  It is reported that the patient has "always been this way" and that is not a change in her behavior.  Mother did think that she did seem a little more depressed, that she seems more lonely.  Over the last few months, she has seemed a little bit more down because she does not have any friends and that she is bored.  Mother reported that she frequently complains of being bored, but has always been this way.  No sleep disturbance was noted.  No changes in weight.  No suicidal ideation.  No deficits in energy were noted.  Mother did report that she does tend to worry, but her worries tend to be because she gets confused, does not understand what she needs to do, and is quite rigid, but mother did not feel that the worry was actually affecting her functioning on a daily basis.,DEVELOPMENTAL HISTORY:,  The patient was the 5 pound 12 ounce product of an unplanned pregnancy and normal spontaneous vaginal delivery.  She was delivered at 36 weeks' gestation.  Mother reported that she received prenatal care.  Difficulties during the pregnancy were denied.  The use of drugs, alcohol, tobacco during the pregnancy were denied.  No eating or sleeping difficulties during the perinatal period were reported.  Temperament was described as easy.  The patient is described as a cuddly baby.  In terms of serious injuries, they were denied.  Serious illnesses:  She has been diagnosed since age 5 with seizures.  Mother was not able to tell me the exact kind of seizures, but it would appear from I could gather that they are focal seizures and possibly simple-to-complex partial seizures.  The patient does not have a history of allergy or toileting problems.  She is currently taking Trileptal 450 mg b.i.d., and she is currently taking Depakote, although she is going to be weaned off the Depakote by her neurologist.  She is taking Prevacid and ibuprofen.  The neurologist that she sees is Dr. Y here at Children's Hospital.,FAMILY BACKGROUND:,  In terms of family background, the patient lives with her mother age 38 and her mother's partner, who is age 40, and with her 16-year-old sister who does not have any developmental delays.  Mother had been married to the patient's father, but they were together as a couple beginning 1990, married in 1997, separated in 2002, and divorced in 2003; he lives in the ABC area and visits them every other Saturday, but there are no overnight visits.  The paternal grandparents are both living here in California, but are separated.  They are 3 paternal uncles and 2 paternal aunts.  In terms of the maternal family, maternal grandmother and grandfather are deceased.  Maternal grandfather deceased in 1991 due to cancer.  Maternal grandmother deceased in 2001 due to cancer.  There are 5 maternal aunts and 2 maternal uncles, all who live in California.  She reported that the patient is particularly close to her maternal aunt, whose name is Carmen.  Mother's partner had been married previously; he has 2 children from that relationship, a 23-year-old, and a 20-year-old female, who really are not part of the patient's daily life.  In terms of other family background, it was reported that the mother's partner gets frustrated with The patient, does not completely understand the degree of her delay and how that may affect her ability to do things as well as her interpretation of things.  The sister was described as having some resentment towards her older sister, that she feels like she was just to watch out for her, care for her, and that sister has always wanted to follow her around and do the things that she does.  The biological father allegedly was in jail for a year due to drug possession.  Mother reported that he had a problem with methamphetamine.  In addition, she reported there is an accusation that he had molested their niece; however, she stated that there was a trial, and he was found to be not guilty of that.  She stated there was no evidence that he had ever molested the patient or her sister.  There had been quite a bit of chaos in the family when the mother and father were together.  There was a lot of arguing.  There were a lot of moves, there was domestic violence both from father to mother and mother to father consisting mostly of pushing and shoving by mother's report.  The patient did observe this.  After the separation, it was reported that there were continued difficulties that the father took the patient and her sister from school without mother's knowledge and had filed to get custody of them and actually ended up having custody of them for a month, and told the patient and her sister that the mother had abandoned them.  Mother reported that they went to court, and there was a court order giving the mother custody back after the father went to jail.  Mother stated that was approximately 5 years ago.  In terms of current, mother reports that she currently works 2 jobs from 8 to 5 on Monday and Friday and from 6 to 10 on Monday, Wednesday's, and Friday's, but she does have the weekends off.  The patient was reported also to have a job through her school on several weeknights.,Mother reported that she graduated from high school, had a year of college.  She was an average student, had learning difficulties in reading.  No psychological or drug or alcohol history was reported by mother.  In terms of the biological father, mother stated that he graduated from high school, had a couple of years of college, was a good student, no learning problems or psychological problems for him were reported.  Mother reported that he had a history of methamphetamine use.,Other psychiatric history in the family was denied.,SOCIAL HISTORY: , She reported that the patient feels like she does not have any friends, that she is lonely and bored, really does not do much for fun.  Her fun consists primarily of doing crafts with mother, sewing, painting, drawing, beadwork, and things like that.  It was reported that she really feels that she is bored and does not have much to do.,ACADEMIC BACKGROUND:  ,The patient is in the 11th grade at High School.  She has 2 regular education classes, mother could not tell me what they were, but the rest of her classes are special education.  Mother could not tell me what her IQ was, although she noticed she works at about a 4th or 5th grade level.  Mother reported that the terminology most often used with the patient was developmental delay.  Her counselor's name is Mr. XYZ, but she reported that overall she is a good student, but she does have sometimes some difficulties at school, becoming upset or angry regarding the little things that she does not seem to understand.  It is reported that the patient feels that she has no friends at school that she is lonely, and that is she does not really care for school.  She reported that the patient is involved in a work program through the school where she works at Pet Extreme on Mondays and Wednesdays from 3 to 8 p.m. where she stocks shelves.  It is reported that she does not like to go to school because she feels like nobody likes her.  She is not involved in any kind of clubs or groups at school.  Mother reported that she is also not receiving CVRC services.,PREVIOUS COUNSELING: , Mother reported that she has been in counseling before, but mother could not give me any information about that, who did the counseling, or what it was about.  She does receive evidently some peer counseling at school because she gets upset and needs help in calming down.,DIAGNOSTIC SUMMARY AND IMPRESSION:,  It appears that the patient best qualifies for a diagnosis of conversion disorder, and information from Neurology suggests that the "seizure episodes" are not true seizures, but appear to be pseudoseizures.  The patient is experiencing quite bit of stress with a lot of changes in her life, also difficulty in functioning likely due to her developmental delay makes it difficult for her to understand.,PLAN:,  My plan is to meet with the patient in approximately 1 to 2 weeks to complete a clinical interview with her, and then to begin teaching coping skills as well as explore ways for reducing her stress.,DSM IV DIAGNOSES:  ,AXIS I:  Conversion disorder (300.11).,AXIS II:  Diagnoses deferred.,AXIS III:  Seizure disorder.,AXIS IV:  Problems with primary support group, peer problems, and educational problems.,AXIS V:  Global assessment of functioning equals 60.
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DESCRIPTION: The patient was referred due to a recent admission for pseudoseizures.

psychiatry / psychology, conversion disorder, global assessment of functioning, primary support group, peer problems, developmental delays, seizures, developmentally, axis, pseudoseizures,

The patient's situation involves a complex interplay of psychiatric, developmental, and family dynamics which are being addressed by medical professionals. Pseudoseizures can be distressing and may impact the patient's quality of life, but the situation does not involve immediate life-threatening conditions. The plan involves ongoing psychiatric support and counseling, which indicates managed and controlled treatment. Key factors include the stress from familial relationships, developmental delays, and social isolation, which contribute to the psychological state necessitating psychiatric intervention. Overall, these make it a medium-stakes situation, primarily impacting the patient’s mental health and quality of life.


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

Medical Specialty: Psychiatry / Psychology
Sample Name: Huntington's Disease - Consult

CHIEF COMPLAINT: , "A lot has been thrown at me.",The patient is interviewed with husband in room.,HISTORY OF PRESENT ILLNESS: , This is a 69-year-old Caucasian woman with a history of Huntington disease, who presented to Hospital four days ago after an overdose of about 30 Haldol tablets 5 mg each and Tylenol tablet 325 mg each, 40 tablets.  She has been on the medical floor for monitoring and is medically stable and was transferred to the psychiatric floor today.  The patient states she had been thinking about suicide for a couple of weeks.  Felt that her Huntington disease had worsened and she wanted to spare her family and husband from trouble.  Reports she has been not socializing with her family because of her worsening depression.  Husband notes that on Monday after speaking to Dr. X, they had been advised to alternate the patient's Pamelor (nortriptyline) to every other day because the patient was reporting dry mouth.  They did as they have instructed and husband feels this may have had some factor on her worsening depression.  The patient decided to ingest the pills when her husband went to work on Friday.  She thought Friday would be a good day because there would be less medical people working so her chances of receiving medical care would be lessened.  Her husband left around 7 in the morning and returned around 11 and found her sleeping.  About 30 minutes after his arrival, he found the empty bottles and woke up the patient to bring her to the hospital.,She says she wishes she would have died, but is happy she is alive and is currently not suicidal because she notes her sons may be have to be tested for the Huntington gene.  She does not clearly explain how this has made her suicidality subside.,This is the third suicide attempt in the last two months for this patient.  About two months ago, the patient took an overdose of Tylenol and some other medication, which the husband and the patient are not able to recall.  She was taken to Southwest Memorial Hermann Hospital.  A few weeks ago, the patient tried to shoot herself and the gun was fired and there is a blow-hole in the floor.  Husband locked the gun after that and she was taken to Bellaire Hospital.  The patient has had three psychiatric admissions in the past two months, two to Southwest Memorial and one to Bellaire Hospital for 10 days.  She sees Dr. X once or twice weekly.  He started seeing her after her first suicide attempt.,The patient's husband and the patient state that until March 2009, the patient was independent, was driving herself around and was socially active.  Since then she has had worsening of her Huntington symptoms including short-term memory loss.  At present, the patient could not operate the microwave or operate her cell phone and her husband says that she is progressively more withdrawn, complains about anxiety, and complains about shortness of breath.  The patient notes that she has had depressive symptoms of quitting social life, the patient being withdrawn for the past few months and excessive worry about her Huntington disease.,The patient's mother passed away 25 years ago from Huntington's.  Her grandmother passed away 50 years ago and two brothers also passed away of Huntington's.  The patient has told her husband that she does not want to go that way.  The patient denies auditory or visual hallucinations, denies paranoid ideation.  The husband and the patient deny any history of manic or hypomanic symptoms in the past.,PAST PSYCHIATRIC HISTORY: , As per the HPI, this is her third suicide attempt in the last two months and started seeing Dr. X.  She has a remote history of being on Lexapro for depression.,MEDICATIONS: , Her medications on admission, alprazolam 0.5 mg p.o. b.i.d., Artane 2 mg p.o. b.i.d., Haldol 2.5 mg p.o. t.i.d., Norvasc 10 mg p.o. daily, nortriptyline 50 mg p.o. daily.  Husband has stated that the patient's chorea becomes better when she takes Haldol.  Alprazolam helps her with anxiety symptoms.,PAST MEDICAL HISTORY: , Huntington disease, symptoms of dementia and hypertension.  She has an upcoming appointment with the Neurologist.  Currently, does have a primary care physician and _______ having an outpatient psychiatrist, Dr. X, and her current Neurologist, Dr. Y.,ALLERGIES: , CODEINE AND KEFLEX.,FAMILY MEDICAL HISTORY:  ,Strong family history for Huntington disease as per the HPI.  Mother and grandmother died of Huntington disease.  Two young brothers also had Huntington disease.,FAMILY PSYCHIATRIC HISTORY: , The patient denies history of depression, bipolar, schizophrenia, or suicide attempts.,SOCIAL HISTORY:  ,The patient lives with her husband of 48 years.  She used to be employed as a registered nurse.  Her husband states that she does have a pattern of self-prescribing for minor illness, but does not think that she has ever taken muscle relaxants or sedative medications without prescriptions.  She rarely drinks socially.  She denies any illicit substance usage.  Her husband reportedly gives her medication daily.  Has been proactive in terms of seeking mental health care and medical care.  The patient and husband report that from March 2009, she has been relatively independent, more socially active.,MENTAL STATUS EXAM:  ,This is an elderly woman appearing stated age.  Alert and oriented x4 with poor eye contact.  Appears depressed, has psychomotor retardation, and some mild involuntary movements around her lips.  She is cooperative.  Her speech is of low volume and slow rate and rhythm.  Her mood is sad.  Her affect is constricted.  Her thought process is logical and goal-directed.  Her thought content is negative for current suicidal ideation.  No homicidal ideation.  No auditory or visual hallucinations.  No command auditory hallucinations.  No paranoia.  Insight and judgment are fair and intact.,LABORATORY DATA:,  A CT of the brain without contrast, without any definite evidence of acute intracranial abnormality.  U-tox positive for amphetamines and tricyclic antidepressants.  Acetaminophen level 206.7, alcohol level 0.  The patient had a leukocytosis with white blood cell of 15.51, initially TSH 1.67, T4 10.4.,ASSESSMENT: , This is a 69-year-old white woman with Huntington disease, who presents with the third suicide attempt in the past two months.  She took 30 tablets of Haldol and 40 tablets of Tylenol.  At present, the patient is without suicidal ideation.  She reports that her worsening depression has coincided with her worsening Huntington disease.  She is more hopeful today, feels that she may be able to get help with her depression.,The patient was admitted four days ago to the medical floor and has subsequently been stabilized.  Her liver function tests are within normal limits.,AXIS I:  Major depressive disorder due to Huntington disease, severe.  Cognitive disorder, NOS.,AXIS II:  Deferred.,AXIS III:  Hypertension, Huntington disease, status post overdose.,AXIS IV:  Chronic medical illness.,AXIS V:  30.,PLAN,1.  Safety.  The patient would be admitted on a voluntary basis to Main-7 North.  She will be placed on every 15-minute checks with suicidal precautions.,2.  Primary psychiatric issues/medical issues.  The patient will be restarted as per written by the consult service for Prilosec 200 mg p.o. daily, nortriptyline 50 mg p.o. nightly, Haldol 2 mg p.o. q.8h., Artane 2 mg p.o. daily, Xanax 0.5 mg p.o. q.12h., fexofenadine 180 mg p.o. daily, Flonase 50 mcg two sprays b.i.d., amlodipine 10 mg p.o. daily, lorazepam 0.5 mg p.o. q.6h. p.r.n. anxiety and agitation.,3.  Substance abuse.  No acute concern for alcohol or benzo withdrawal.,4.  Psychosocial.  Team will update and involve family as necessary.,DISPOSITION: , The patient will be admitted for evaluation, observation, treatment.  She will participate in the milieu therapy with daily rounds, occupational therapy, and group therapy.  We will place occupational therapy consult and social work consults.
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DESCRIPTION: This is a 69-year-old white woman with Huntington disease, who presents with the third suicide attempt in the past two months.

The situation involves multiple recent suicide attempts by a patient with a severe chronic illness, Huntington's disease, which significantly affects her mental health. The patient has expressed suicidal ideation and has a strong family history of the disease, which exacerbates the psychological burden. The complexity of managing her psychiatric needs in conjunction with her medical condition makes this a high-stakes situation. Factors such as her prior attempts, the seriousness of the overdose, and her ongoing depressive symptoms underscore the critical nature of the medical and psychological interventions required to prevent further harm.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Psychiatry / Psychology
Sample Name: Falls - Discharge Summary

CHIEF COMPLAINT:,  Falls at home.,HISTORY OF PRESENT ILLNESS:,  The patient is an 82-year-old female who fell at home and presented to the emergency room with increased anxiety.  Family members who are present state that the patient had been increasingly anxious and freely admitted that she was depressed at home.  They noted that she frequently came to the emergency room for "attention."  The patient denied any chest pain or pressure and no change to exercise tolerance.  The patient denied any loss of consciousness or incontinence.  She denies any seizure activity.  She states that she "tripped" at home.  Family states she frequently takes Darvocet for her anxiety and that makes her feel better, but they are afraid she is self medicating.  They stated that she has numerous medications at home, but they were not sure if she was taking them.  The patient been getting along for a number of years and has been doing well, but recently has been noting some decline primarily with regards to her depression.  The patient denied SI or HI.,PHYSICAL EXAMINATION:,GENERAL:  The patient is pleasant 82-year-old female in no acute distress.,VITAL SIGNS:  Stable.,HEENT:  Negative.,NECK:  Supple.  Carotid upstrokes are 2+.,LUNGS:  Clear.,HEART:  Normal S1 and S2.  No gallops.  Rate is regular.,ABDOMEN:  Soft.  Positive bowel sounds.  Nontender.,EXTREMITIES:  No edema.  There is some ecchymosis noted to the left great toe.  The area is tender; however, metatarsal is nontender.,NEUROLOGICAL:  Grossly nonfocal.,HOSPITAL COURSE: , A psychiatric evaluation was obtained due to the patient's increased depression and anxiety.  Continue Paxil and Xanax use was recommended.  The patient remained medically stable during her hospital stay and arrangements were made for discharge to a rehabilitation program given her recent falls.,DISCHARGE DIAGNOSES:,1.  Falls ,2.  Anxiety and depression.,3.  Hypertension.,4.  Hypercholesterolemia.,5.  Coronary artery disease.,6.  Osteoarthritis.,7.  Chronic obstructive pulmonary disease.,8.  Hypothyroidism.,CONDITION UPON DISCHARGE: , Stable.,DISCHARGE MEDICATIONS: , Tylenol 650 mg q.6h. p.r.n., Xanax 0.5 q.4h. p.r.n., Lasix 80 mg daily, Isordil 10 mg t.i.d., KCl 20 mEq b.i.d., lactulose 10 g daily, Cozaar 50 mg daily, Synthroid 75 mcg daily, Singulair 10 mg daily, Lumigan one drop both eyes at bed time, NitroQuick p.r.n., Pravachol 20 mg daily, Feldene 20 mg daily, Paxil 20 mg daily, Minipress 2 mg daily, Provera p.r.n., Advair 250/50 one puff b.i.d., Senokot one tablet b.i.d., Timoptic one drop OU daily, and verapamil 80 mg b.i.d.,ALLERGIES: , None.,ACTIVITY: , Per PT.,FOLLOW-UP: , The patient discharged to a skilled nursing facility for further rehabilitation.
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DESCRIPTION: Falls at home.  Anxiety and depression.  The patient had been increasingly anxious and freely admitted that she was depressed at home.

This situation involves an elderly patient who has experienced falls at home, coupled with increased anxiety and depression. The patient has multiple chronic health conditions, takes numerous medications, and there are concerns about self-medication with Darvocet. While the patient is medically stable upon discharge, the complex interplay of psychiatric issues, potential medication mismanagement, and rehabilitation needs signify high stakes. The risks include potential for future falls, worsening mental health, improper medication use, and insufficient home support. The involvement of a rehabilitation program post-discharge and the coordination of care with psychiatric evaluation highlight that this is a higher stakes situation, primarily due to the patient's vulnerability and the complexity of managing her health needs effectively.


Medical Specialty: Podiatry
Sample Name: Tarsectomy

PREOPERATIVE DIAGNOSES:,1.  Painful enlarged navicula, right foot.,2.  Osteochondroma of right fifth metatarsal.,POSTOPERATIVE DIAGNOSES:,1.  Painful enlarged navicula, right foot.,2.  Osteochondroma of right fifth metatarsal.,PROCEDURE PERFORMED:,1.  Partial tarsectomy navicula, right foot.,2.  Partial metatarsectomy, right foot.,HISTORY:  ,This 41-year-old Caucasian female who presents to ABCD General Hospital with the above chief complaint.  The patient states that she has extreme pain over the navicular bone with shoe gear as well as history of multiple osteochondromas of unknown origin.  She states that she has been diagnosed with hereditary osteochondromas.  She has had previous dissection of osteochondromas in the past and currently has not been diagnosed in her feet as well as spine and back.  The patient desires surgical treatment at this time.,PROCEDURE:  ,An IV was instituted by the Department of Anesthesia in the preoperative holding area.  The patient was transported to the operating room and placed on operating table in the supine position with a safety belt across her lap.  Copious amounts of Webril were placed on the left ankle followed by a blood pressure cuff.  After adequate sedation by the Department of Anesthesia, a total of 5 cc of 1:1 mixture of 1% lidocaine plain and 0.5% Marcaine plain were injected in the diamond block type fashion around the navicular bone as well as the fifth metatarsal.  Foot was then prepped and draped in the usual sterile orthopedic fashion.,Foot was elevated from the operating table and exsanguinated with an Esmarch bandage.  The pneumatic ankle tourniquet was then inflated to 250 mmHg.  The foot was lowered as well as the operating table.  The sterile stockinet was reflected and the foot was cleansed with wet and dry sponge.  Attention was then directed to the navicular region on the right foot.  The area was palpated until the bony prominence was noted.  A curvilinear incision was made over the area of bony prominence.  At that time, a total of 10 cc with addition of 1% additional lidocaine plain was injected into the surgical site.  The incision was then deepened with #15 blade.  All vessels encountered were ligated for hemostasis.  The dissection was carried down to the level of the capsule and periosteum.  A linear incision was made over the navicular bone obliquely from proximal dorsal to distal plantar over the navicular bone.  The periosteum and the capsule were then reflected from the navicular bone at this time.  A bony prominence was noted both medially and plantarly to the navicular bone.  An osteotome and mallet were then used to resect the enlarged portion of the navicular bone.  After resection with an osteotome there was noted to be a large plantar shelf.  The surrounding soft tissues were then freed from this plantar area.  Care was taken to protect the attachments of the posterior tibial tendon as much as possible.  Only minimal resection of its attachment to the fiber was performed in order to expose the bone.  Sagittal saw was then used to resect the remaining plantar medial prominent bone.  The area was then smoothed with reciprocating rasp until no sharp edges were noted.  The area was flushed with copious amount of sterile saline at which time there was noted to be a palpable ________ where the previous bony prominence had been noted.  The area was then again flushed with copious amounts of sterile saline and the capsule and periosteum were then reapproximated with #3-0 Vicryl.  The subcutaneous tissues were then reapproximated with #4-0 Vicryl to reduce tension from the incision and running #5-0 Vicryl subcuticular stitch was performed.,Attention was then directed to the fifth metatarsal.  There was noted to be a palpable bony prominence dorsally with fifth metatarsal head as well as radiographic evidence laterally of an osteochondroma at the neck of the fifth metatarsal.  Approximately 7 cm incision was made dorsolaterally over the fifth metatarsal.  The incision was then deepened with #15 blade.  Care was taken to preserve the extensor tendon.  The incision was then created over the capsule and periosteum of the fifth metatarsal head.  Capsule and periosteum were reflected both dorsally, laterally, and plantarly.  At that time, there was noted to be a visible osteochondroma on the plantar lateral aspect of the fifth metatarsal neck as well as on the dorsal aspect of the head of the fifth metatarsal.  A sagittal saw was used to resect both of these osteal prominences.,All remaining sharp edges were then smoothed with reciprocating rasp.  The area was inspected for the remaining bony prominences and none was noted.  The area was flushed with copious amounts of sterile saline.  The capsule and periosteum were then reapproximated with #3-0 Vicryl.  Subcutaneous closure was then performed with #4-0 Vicryl in order to reduce tension around the incision line.  Running #5-0 subcutaneous stitch was then performed.  Steri-Strips were applied to both surgical sites.  Dressings consisted of Adaptic, soaked in Betadine, 4x4s, Kling, Kerlix, and Coban.  The pneumatic ankle tourniquet was released and the hyperemic flush was noted to all five digits of the right foot.,The patient tolerated the above procedure and anesthesia well without complications.  The patient was transferred to the PACU with vital signs stable and vascular status intact.  The patient was given postoperative pain prescription and instructed to be partially weightbearing with crutches as tolerated.  The patient is to follow-up with Dr. X in his office as directed or sooner if any problems or questions arise.
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DESCRIPTION: Painful enlarged navicula, right foot.  Osteochondroma of right fifth metatarsal. Partial tarsectomy navicula and partial metatarsectomy, right foot.

podiatry, navicula, metatarsal, osteochondroma, tarsectomy, metatarsectomy, painful enlarged navicula, navicular bone, foot, bony, capsule, periosteum, navicular, incision, bone

The procedure described is a surgical intervention involving the resection of bone parts from the navicular region and fifth metatarsal of the right foot. While surgical procedures inherently carry risks, especially those requiring general anesthesia and involving incisions near tendons and important vasculature, podiatric surgeries like the one described typically have low morbidity. Moreover, the patient's condition, while painful, does not seem to be life-threatening or likely to cause significant disability if managed properly. The procedure is routine in nature for the condition presented, and the postoperative prognosis appears favorable with no complications noted, which further reduces the stakes.


Medical Specialty: Podiatry
Sample Name: Tinea Pedis - H&P

CHIEF COMPLAINT (1/1):  ,This 24 year-old female presents today complaining of itchy, red rash on feet.  Associated signs and symptoms:  Associated signs and symptoms include tingling, right.  Context:  Patient denies any previous history, related trauma or previous treatments for this condition.  Duration:  Condition has existed for 4 weeks.  Location:  She indicates the problem location is right great toe, right 2nd toe, right 3rd toe and right 4th toe.  Modifying factors:  Patient indicates ice improves condition.  Quality:  Quality of the itch is described by the patient as constant.  Severity:  Severity of condition is unbearable.  Timing (onset/frequency):  Onset was after leaving on sweaty socks.,ALLERGIES: , Patient admits allergies to adhesive tape resulting in severe rash.,MEDICATION HISTORY:,  None.,PAST MEDICAL HISTORY: , Childhood Illnesses: (+) chickenpox, (+) frequent ear infections.,PAST SURGICAL HISTORY:  ,Patient admits past surgical history of ear tubes.,SOCIAL HISTORY: , Patient admits alcohol use Drinking is described as social, Patient denies tobacco use, Patient denies illegal drug use, Patient denies STD history.,FAMILY HISTORY:,  Patient admits a family history of cataract associated with maternal grandmother,,headaches/migraines associated with maternal aunt.,REVIEW OF SYSTEMS:,  Unremarkable with exception of chief complaint.,PHYSICAL EXAM: , BP Sitting:  110/64 Resp:  18 HR:  66 Temp:  98.6,Patient is a 24 year old female who appears well developed, well nourished and with good attention to hygiene and body habitus.  Cardiovascular:  Skin temperature of the lower extremities is warm to cool, proximal to distal.,DP pulses palpable bilateral.,PT pulses palpable bilateral.,CFT immediate.,No edema observed.,Varicosities are not observed.  Skin:  Right great toe, right 2nd toe, right 3rd toe and right 4th toenail shows erythema and scaling.,Neurological:  Touch, pin, vibratory and proprioception sensations are normal.  Deep tendon reflexes normal.,Musculoskeletal:  Muscle strength is 5/5 for all groups tested.  Muscle tone is normal.  Inspection and palpation of bones, joints and muscles is unremarkable.,TEST RESULTS:,  No tests to report at this time,IMPRESSION: , Tinea pedis.,PLAN:  ,Obtained fungal culture of skin from right toes.  KOH prep performed revealed no visible microbes.,PRESCRIPTIONS:,  Lotrimin AF  Dosage:  1% cream  Sig:  apply qid  Dispense:  4oz tube Refills:  0  Allow Generic:  Yes
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DESCRIPTION: Itchy red rash on feet - Tinea Pedis

Itchy red rash on feet - Tinea Pedis

The situation described involves a medical assessment of a condition known as Tinea Pedis, which is a common fungal infection also known as athlete's foot. It generally represents low-stakes from a medical perspective as it is not life-threatening and is a condition that can typically be treated effectively with antifungal medication. The patient presents with typical symptoms that are uncomfortable but not dangerous, and the planned treatment is standard for this condition. Therefore, while the condition causes discomfort, it does not pose a significant risk to the patient's overall health, making it a low-stakes medical scenario.


Medical Specialty: Psychiatry / Psychology
Sample Name: Asperger Disorder

SUBJECTIVE:  ,School reports continuing difficulties with repetitive questioning, obsession with cleanness on a daily basis, concerned about his inability to relate this well in the classroom.  He appears confused and depressed at times.  Mother also indicates that preservative questioning had come down, but he started collecting old little toys that he did in the past.  He will attend social skills program in the summer.  ABCD indicated to me that they have identified two psychologists to refer him to for functional behavioral analysis.  There is lessening of tremoring in both hands since discontinuation of Zoloft.  He is now currently taking Abilify at 7.5 mg.,OBJECTIVE: , He came in less perseverative questioning, asked appropriate question about whether I talked to ABCD or not, greeted me with Japanese word to say hello, seemed less.,I also note that his tremors were less from the last time.,ASSESSMENT: , 299.8 Asperger disorder, 300.03 obsessive compulsive disorder.,PLAN:,  Decrease Abilify from 7.5 mg to 5 mg tablet one a day, no refills needed.  I am introducing slow Luvox 25 mg tablet one-half a.m. for OCD symptoms, if no side effects in one week we will to tablet one up to therapeutic level.,I also will call ABCD regarding the referral to psychologists for functional behavioral analysis.  Parents will call me in two weeks.  I will see him for medication review in four weeks.  Mother signed informed consent.  I reviewed side effects to observe including behavioral activation.,Abilify has been helpful in decreasing high emotional arousal.  Combination of medication and behavioral intervention is recommended.
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DESCRIPTION: School reports continuing difficulties with repetitive questioning, obsession with cleanness on a daily basis, concerned about his inability to relate this well in the classroom.   Asperger disorder.  Obsessive compulsive disorder.

psychiatry / psychology, repetitive questioning, obsession with cleanness, inability to relate, obsessive compulsive disorder, functional behavioral analysis, asperger disorder, inability, asperger,

This situation involves the management and treatment plan for a patient with Asperger disorder and obsessive-compulsive disorder. While the clinical decisions made regarding medication adjustment and behavioral interventions can significantly impact the patient's well-being and social functioning, they are part of a controlled, regular mental health management process, which involves monitoring and adjustments over time. There is no immediate life-threatening risk indicated, and adjustments seem to be precautionary and part of ongoing care. Thus, the stakes are moderate as they are important for the individual's quality of life and development, but not critical in terms of immediate danger.


Medical Specialty: Psychiatry / Psychology
Sample Name: Agitation - ER Visit

HISTORY OF PRESENT ILLNESS:  This is a 91-year-old female who was brought in by family.  Apparently, she was complaining that she felt she might have been poisoned at her care facility.  The daughter who accompanied the patient states that she does not think anything is actually wrong, but she became extremely agitated and she thinks that is the biggest problem with the patient right now.  The patient apparently had a little bit of dry heaves, but no actual vomiting.  She had just finished eating dinner.  No one else in the facility has been ill.,PAST MEDICAL HISTORY: Remarkable for previous abdominal surgeries.  She has a pacemaker.  She has a history of recent collarbone fracture.,REVIEW OF SYSTEMS:  Very difficult to get from the patient herself.  She seems to deny any significant pain or discomfort, but really seems not particularly intent on letting me know what is bothering her.  She initially stated that everything was wrong, but could not specify any specific complaints.  Denies chest pain, back pain, or abdominal pain.  Denies any extremity symptoms or complaints.,SOCIAL HISTORY:  The patient is a nonsmoker.  She is accompanied here with daughter who brought her over here.  They were visiting the patient when this episode occurred.,MEDICATIONS:  Please see list.,ALLERGIES:  NONE.,PHYSICAL EXAMINATION:  VITAL SIGNS:  The patient is afebrile, actually has a very normal vital signs including normal pulse oximetry at 99% on room air.  GENERAL:  The patient is an elderly frail looking little lady lying on the gurney.  She is awake, alert, and not really wanted to answer most of the questions I asked her.  She does have a tremor with her mouth, which the daughter states has been there for "many years".  HEENT:  Eye exam is unremarkable.  Oral mucosa is still moist and well hydrated.  Posterior pharynx is clear.  NECK:  Supple.  LUNGS:  Actually clear with good breath sounds.  There are no wheezes, no rales, or rhonchi.  Good air movement.  CARDIAC:  Without murmur.  ABDOMEN:  Soft.  I do not elicit any tenderness.  There is no abdominal distention.  Bowel sounds are present in all quadrants.  SKIN:  Skin is without rash or petechiae.  There is no cyanosis.  EXTREMITIES:  No evidence of any trauma to the extremities.,EMERGENCY DEPARTMENT COURSE:  I had a long discussion with the family and they would like the patient receive something for agitation, so she was given 0.5 mg of Ativan intramuscularly.  After about half an hour, I came back to talk to the patient and the family, the patient states that she feels better.  Family states she seems more calm.  They do not want to pursue any further workup at this time.,IMPRESSION:  ACUTE EPISODE OF AGITATION.,PLAN:  At this time, I had reviewed the patient's records and it is not particularly enlightening as to what could have triggered off this episode.  The patient herself has good vital signs.  She does not seem to have any specific acute process going on and seemed to feel comfortable after the Ativan was given, a small quantity was given to the patient.  Family and daughter specifically did not want to pursue any workup at this point, which at this point I think is reasonable and we will have her follow up with ABC.  She is discharged in stable condition.
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DESCRIPTION: Acute episode of agitation.  She was complaining that she felt she might have been poisoned at her care facility.

psychiatry / psychology, acute episode of agitation, agitation,

The situation involves a 91-year-old female experiencing an acute episode of agitation, which led to an emergency room visit. While the episode seemed distressing, her vital signs were stable, and physical examination showed no immediate signs of a serious underlying condition. The patient received Ativan, after which she and her family reported improvement. The family declined further workup, and she was discharged in stable condition. Agitation in the elderly can indicate various issues, but given the resolution with basic care and her stable discharge, the stakes appear moderate rather than high.


Medical Specialty: Podiatry
Sample Name: Onychomycosis - H&P

CHIEF COMPLAINT (1/1):, This 59 year old female presents today complaining that her toenails are discolored, thickened, and painful. Duration: Condition has existed for 6 months. Severity: Severity of condition is worsening.,ALLERGIES: ,Patient admits allergies to dairy products, penicillin.,MEDICATION HISTORY:, None.,PAST MEDICAL HISTORY:, Past medical history is unremarkable.,PAST SURGICAL HISTORY:, Patient admits past surgical history of eye surgery in 1999.,SOCIAL HISTORY:, Patient denies alcohol use, Patient denies illegal drug use, Patient denies STD history, Patient denies tobacco use.,FAMILY HISTORY:, Unremarkable.,REVIEW OF SYSTEMS:, Psychiatric: (+) poor sleep pattern, Respiratory: (+) breathing difficulties, respiratory symptoms.,PHYSICAL EXAM:, Patient is a 59 year old female who appears well developed, well nourished and with good attention to hygiene and body habitus. Toenails 1-5 bilateral appear crumbly, discolored - yellow, friable and thickened.,Cardiovascular: DP pulses palpable bilateral. PT pulses palpable bilateral. CFT immediate. No edema observed.  Varicosities are not observed.,Skin: Skin temperature of the lower extremities is warm to cool, proximal to distal. No skin rash, subcutaneous nodules, lesions or ulcers observed.,Neurological: Touch, pin, vibratory and proprioception sensations are normal. Deep tendon reflexes normal.,Musculoskeletal: Muscle strength is 5/5 for all groups tested. Muscle tone is normal. Inspection and palpation of bones, joints and muscles is unremarkable.,TEST RESULTS:, No tests to report at this time.,IMPRESSION:, Onychomycosis.,PLAN:, Debrided 10 nails.,PRESCRIPTIONS:, Penlac Dosage: 8% Topical Solution Sig:
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DESCRIPTION: Toenails are discolored, thickened, and painful - Onychomycosis

The situation described is medically significant but not life-threatening. Onychomycosis is a common fungal infection of the toenails that can cause discomfort and pain, as described by the patient. However, it typically does not lead to serious health complications if treated. The primary concern is patient discomfort and potential impact on quality of life, which are important but not immediately critical. The treatment plan involves debridement and prescription of Penlac, a topical antifungal agent, indicating that it is being addressed. However, there is an allergy to penicillin, which requires ensuring no cross-reactive medication is used. This situation is typical and routine in a podiatric context.


Medical Specialty: Podiatry
Sample Name: Phalanx Amputation

PREOPERATIVE DIAGNOSIS:,  Osteomyelitis, right hallux.,POSTOPERATIVE DIAGNOSIS: , Osteomyelitis, right hallux.,PROCEDURE PERFORMED:,  Amputation distal phalanx and partial proximal phalanx, right hallux.,ANESTHESIA:,  TIVA/local.,HISTORY:,  This 44-year-old male patient was admitted to ABCD General Hospital on 09/02/2003 with a diagnosis of osteomyelitis of the right hallux and cellulitis of the right lower extremity.  The patient has a history of diabetes and has had a chronic ulceration to the right hallux and has been on outpatient antibiotics, which he failed.  The patient after a multiple conservative treatments such as wound care antibiotics, the patient was given the option of amputation as a treatment for the chronic resistant osteomyelitis.  The patient desires to attempt a surgical correction.  The risks versus benefits of the procedure were discussed with the patient in detail by Dr. X.  The consent was available on the chart for review.,PROCEDURE IN DETAIL: , After patient was taken to the operating room via cart and placed on the operating table in the supine position, a safety strap was placed across his waist.  Adequate IV sedation was administered by the Department of Anesthesia and a total of 3.5 cc of 1:1 mixture 1% lidocaine and 0.5% Marcaine plain were injected into the right hallux as a digital block.  The foot was prepped and draped in the usual aseptic fashion lowering the operative field.,Attention was directed to the hallux where there was a full-thickness ulceration to the distal tip of the hallux measuring 0.5 cm x 0.5 cm.  There was a ________ tract, which probed through the distal phalanx and along the sides of the proximal phalanx laterally.  The toe was 2.5 times to the normal size.  There were superficial ulcerations in the medial arch of both feet secondary to history of a burn, which were not infected.  The patient had dorsalis pedis and posterior tibial pulses that were found to be +2/4 bilaterally preoperatively.  X-ray revealed complete distraction of the distal phalanx and questionable distraction of the lateral aspect of the proximal phalanx.  A #10 blade was used to make an incision down the bone in a transverse fashion just proximal to the head of the proximal phalanx.  The incision was carried mediolaterally and plantarly encompassing the toe leaving a large amount of plantar skin intact.  Next, the distal phalanx was disarticulated at the interphalangeal joint and removed.  The distal toe was amputated and sent to laboratory for bone culture and sensitivity as well as tissue pathology.  Next, the head of the proximal phalanx was inspected and found to be soft on the distal lateral portion as suspected.  Therefore, a sagittal saw was used to resect approximately 0.75 cm of the distal aspect of head of the proximal phalanx.  This bone was also sent off for culture and was labeled proximal margin.  Next, the flexor hallucis longus tendon was identified and retracted as far as possible distally and transected.  The flexor tendon distally was gray discolored and was not viable.  A hemostat was used to inspect the flexor sheath to ensure no infection tracking up the sheath proximally.  None was found.  No purulent drainage or abscess was found.  The proximal margin of the surgical site tissue was viable and healthy.  There was no malodor.  Anaerobic and aerobic cultures were taken and passed this as a specimen to microbiology.  Next, copious amounts of gentamicin and impregnated saline were instilled into the wound.,A #3-0 Vicryl was used to reapproximate the deep subcutaneous layer to release skin tension.  The plantar flap was viable and was debulked with Metzenbaum scissors.  The flap was folded dorsally and reapproximated carefully with #3-0 nylon with a combination of simple interrupted and vertical mattress sutures.  Iris scissors were used to modify and remodel the plantar flap.  An excellent cosmetic result was achieved.  No tourniquet was used in this case.  The patient tolerated the above anesthesia and surgery without apparent complications.  A standard postoperative dressing was applied consisting of saline-soaked Owen silk, 4x4s, Kerlix, and Coban.  The patient was transported via cart to Postanesthesia Care Unit with vital signs able and vascular status intact to right foot.  He will be readmitted to Dr. Katzman where we will continue to monitor his blood pressure and regulate his medications.  Plan is to continue the antibiotics until further IV recommendations.,He will be nonweightbearing to the right foot and use crutches.  He will elevate his right foot and rest the foot, keep it clean and dry.  He is to follow up with Dr. X on Monday or Tuesday of next week.
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DESCRIPTION: Amputation distal phalanx and partial proximal phalanx, right hallux.   Osteomyelitis, right hallux.

podiatry, osteomyelitis, phalanx, phalanx amputation, proximal margin, plantar flap, distal phalanx, proximal phalanx, proximal, hallux, amputation, foot, plantarly, distal

The case involves the amputation of the distal and partial proximal phalanx of the right hallux due to chronic osteomyelitis in a diabetic patient. While the patient is undergoing a significant surgical procedure, this is a common medical treatment for resistant infections that do not respond to antibiotics. The stakes are moderately high due to the patient's underlying diabetes, which complicates healing and increases the risk of postoperative complications. However, the procedure does not involve immediate life-threatening circumstances for the patient, and the practice is standard in podiatric treatments for such conditions.


Medical Specialty: Podiatry
Sample Name: Onychomycosis - 1

S: , The patient presents to podiatry clinic today at the request of her primary physician, Dr. XYZ for initial examination, evaluation, and treatment of her nails.  The patient has last seen primary in December 2006.,PRIMARY MEDICAL HISTORY: , Edema, venous insufficiency, schizophrenia, and anemia.,ALLERGIES: , THE PATIENT HAS NO KNOWN ALLERGIES.,MEDICATIONS: , Refer to chart.,O: , The patient presents in wheelchair, verbal and alert.  Vascular:  She has absent pedal pulses bilaterally.  Trophic changes include absent hair growth and mycotic nails.  Skin texture is dry.  Skin color is rubor.  Classic findings include temperature change and  edema +1.  Nails:  Hypertrophic with crumbly subungual debris, #1, #2, #3, #4, and #5 right and #1, #2, #3, #4, and #5 left.,A:,1.  Onychomycosis present, #1, #2, #3, #4, and #5 right and left.,2.  Peripheral vascular disease as per classic findings.,3.  Pain on palpation.,P: , Nails #1, #2, #3, #4, and #5 right and #1, #2, #3, #4, and #5 left were debrided for length and thickness.  The patient will be seen again at the request of the nursing staff for treatment of painful mycotic nails.
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DESCRIPTION: Onychomycosis present, #1, #2, #3, #4, and #5 right and left.

podiatry, debrided, thickness, mycotic nails, onychomycosis, nails,

The situation involves a patient with several health concerns being treated for onychomycosis (a fungal nail infection) in a podiatry clinic. Despite the presence of multiple comorbidities such as peripheral vascular disease and schizophrenia, the immediate context (onychomycosis treatment) has limited urgency. Onychomycosis, while uncomfortable and capable of affecting quality of life, is typically not life-threatening. However, given the patient's existing health issues including peripheral vascular disease, there is some risk as the foot health of this patient requires careful management. Therefore, this situation isn't extremely high-stakes, but it does involve ongoing health supervision to potentially prevent complications.


Medical Specialty: Podiatry
Sample Name: Mass Excision - Foot

PREOPERATIVE DIAGNOSIS: , Soft tissue mass, right foot.,POSTOPERATIVE DIAGNOSIS: , Soft tissue mass, right foot.,PROCEDURE PERFORMED: , Excision of soft tissue mass, right foot.,HISTORY:  ,The patient is a 51-year-old female with complaints of soft tissue mass over the dorsum of the right foot.  The patient has had previous injections to the site which have caused the mass to decrease in size, however, the mass continues to be present and is irritated and painful with shoes.  The patient has requested surgical intervention at this time.,PROCEDURE:  ,After an IV was instituted by the Department of Anesthesia, the patient was escorted from the preoperative holding area to the operating room.  The patient was then placed on the operating room table in the supine position and a towel was placed around the patient's abdomen and secured her to the table.  Using copious amounts of Webril, a pneumatic ankle tourniquet was applied to her right ankle.  Using a Skin Skribe, the area of the soft tissue mass was outlined over the dorsum of her foot.  After adequate amount of anesthesia was provided by the Department of Anesthesia, a local ankle block was given using 10 cc of 4.5 mL of 1% lidocaine plain, 4.5 mL of 0.5% Marcaine plain and 1.0 mL of Solu-Medrol and the foot was scrubbed and prepped in a normal sterile orthopedic manner.  Following this, the ankle was elevated and Esmarch bandage applied to exsanguinate the foot and the ankle tourniquet was inflated to 250 mmHg.  The foot was then brought back down to the table using bandage scissors.  The stockinette was reflected and the right foot was exposed.  Using a fresh #10 blade, a curvilinear incision was performed over the dorsum of the right foot.  Then using a #15 blade, the incision was deepened with care taken to identify and avoid or cauterize any bleeders which were noted.  Following this, the incision was deepened using a combination of sharp and blunt dissection and the muscle belly of the extensor digitorum brevis muscle was identified.  Further dissection was then performed in the medial direction in the area of the soft tissue mass.  The intermediate dorsal cutaneous nerve was identified and gently retracted laterally.  Large amounts of adipose tissue were noted medial to the belly of the extensor digitorum brevis muscle.  Using careful dissection, adipose tissue in this area was removed and saved for pathology.  Following removal of adipose tissue in this area and identification of no more adipose tissue, attention was directed lateral to the belly of the extensor digitorum brevis muscle, which was also noted to have large amounts of adipose tissue in this area as well.  Using careful dissection, from the lateral border of the foot as much adipose tissue as possible was removed from this area as well and saved for pathology.  There was noted to be no other fluid-filled masses or lesions identifiable in this area then between the slits of the extensor digitorum brevis muscle, careful dissection was performed to examine the underside of the belly of the muscle as well as structures beneath and no abnormal structures were identified here as well.  Following this, feeling adequately that no other mass remained in the area, the incision was flushed using copious amounts of sterile saline.  The wound was then reinspected and all remaining tissues appeared healthy including the subcutaneous tissue.  The tendon and muscle belly of the extensor digitorum brevis muscle, the nerves of the intermediate dorsal cutaneous nerve and also the medial dorsal cutaneous nerve which were identified medially, all appeared intact.  No deficits were noted.  No abnormal appearing tissue was present within the surgical site.  Following this, the skin edges were reapproximated using #4-0 Vicryl deep closure of the subcutaneous layer was performed.  Then, using #4-0 nylon and simple interrupted suture, the skin was reapproximated and closed with care taken to ensure eversion of the skin edges and good approximation of the borders.  The patient was also given 7 cc of 1% lidocaine plain throughout the procedure to augment local anesthesia.  Following this, the wound was dressed using Xeroform gauze and 4x4s and was dressed using two ABD pads, dorsal and plantar for compression and using Kling, Kerlix and Coban.  The patient then had the ankle tourniquet deflated with a total tourniquet time of 55 minutes at 250 mmHg and immediate hyperemia was noted to digits one through five of the right foot.  The patient tolerated the procedure and anesthesia well and was noted to have vascular status intact.  The patient was then escorted to the Postanesthesia Care Unit where she was placed in a surgical shoe.  The patient was then given postoperative instructions to include ice and elevation to her right foot.  The patient was cleared for ambulation as tolerated, but was instructed that with increased ambulation will come increased swelling and pain.  The patient will follow up with Dr. X in his office on Tuesday, 08/26/03 for further follow up.  The patient was given prescription for Vicoprofen #25 taken one tablet q.4h. p.r.n., moderate to severe pain and also prescription for Keflex #20 500 mg tablets to be taken b.i.d. x10 days.  The patient was given a number for the Emergency Room and instructed to return if any sign or symptom of infection should present and the patient was educated as to the nature of these.  The patient had no further questions and recovered without any complications in the Postanesthesia Care Unit.
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DESCRIPTION: Excision of soft tissue mass, right foot.  The patient is a 51-year-old female with complaints of soft tissue mass over the dorsum of the right foot.

podiatry, excision, digitorum brevis muscle, soft tissue mass, adipose tissue, soft tissue, mass, injections, foot, tissue, xeroform, dorsum, belly, extensor, digitorum, brevis, ankle, adipose, muscle,

The procedure described is a routine surgical intervention to excise a soft tissue mass from the patient's foot. While it involves general anesthesia and surgical removal of tissue, it is not typically considered high-stakes. The presence of pathology testing is standard procedure to rule out malignancy, but there is no immediate indication of cancer or life-threatening conditions. The patient's vitals and vascular status were intact post-surgery, which suggests the procedure went without complications. Furthermore, the postoperative instructions are standard, and the patient is advised to follow up as is typical for such procedures.


Medical Specialty: Podiatry
Sample Name: Infected Toenails

S - ,This patient has reoccurring ingrown infected toenails.  He presents today for continued care.,O - ,On examination, the left great toenail is ingrown on the medial and lateral toenail border.  The right great toenail is ingrown on the lateral nail border only.  There is mild redness and granulation tissue growing on the borders of the toes.  One on the medial and one on the lateral aspect of the left great toe and one on the lateral aspect of the right great toe.  These lesions measure 0.5 cm in diameter each.  I really do not understand why this young man continues to develop ingrown nails and infections.,A - ,1.  Onychocryptosis.,
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DESCRIPTION: This patient has reoccurring ingrown infected toenails.

podiatry, infected toenails, onychocryptosis, benign lesions, toenail border, left great toe, neosporin ointment, hemostasis was achieved, ointment and absorbent, toenails, ingrown, lesions, benign, infected,

The situation involves a patient with recurrent ingrown toenails and accompanying infections. While these can cause significant discomfort and may lead to more serious issues if not treated (such as spreading infection), they are generally not immediately life-threatening or high-stakes. They may require surgical intervention to prevent recurrence, but this is typically planned and not an emergency procedure. Therefore, it is a moderately concerning condition from a health maintenance and quality of life perspective but not high-stakes in an acute medical sense.


Medical Specialty: Podiatry
Sample Name: Hallux Infected Bone Resection

PREOPERATIVE DIAGNOSIS: , Osteomyelitis, left hallux.,POSTOPERATIVE DIAGNOSIS: , Osteomyelitis, left hallux.,PROCEDURES PERFORMED: , Resection of infected bone, left hallux, proximal phalanx, and distal phalanx.,ANESTHESIA: , TIVA/Local.,HISTORY:,  This 77-year-old male presents to ABCD preoperative holding area after keeping himself NPO since mid night for surgery on his infected left hallux.  The patient has a history of chronic osteomyelitis and non-healing ulceration to the left hallux of almost 10 years' duration.  He has failed outpatient antibiotic therapy and conservative methods.  At this time, he desires to attempt surgical correction.  The patient is not interested in a hallux amputation at this time; however, he is consenting to removal of infected bone.  He was counseled preoperatively about the strong probability of the hallux being a "floppy tail" after the surgery and accepts the fact.  The risks versus benefits of the procedure were discussed with the patient in detail by Dr. X and the consent is available on the chart for review.,PROCEDURE IN DETAIL:  ,The patient's wound was debrided with a #15 blade and down to good healthy tissue preoperatively.  The wound was on the planar medial, distal and dorsal medial.  The wound's bases were fibrous.  They did not break the bone at this point.  They were each approximately 0.5 cm in diameter.  After IV was established by the Department of Anesthesia, the patient was taken to the operating room and placed on the operating table in supine position with safety straps placed across his waist for his protection.,Due to the patient's history of diabetes and marked calcifications on x-ray, a pneumatic ankle tourniquet was not applied.  Next, a total of 3 cc of a 1:1 mixture of 0.5% Marcaine plain and 1% lidocaine plain was used to infiltrate the left hallux and perform a digital block.  Next, the foot was prepped and draped in the usual aseptic fashion.  It was lowered in the operative field and attention was directed to the left hallux after the sterile stockinet was reflected.  Next, a #10 blade was used to make a linear incision approximately 3.5 cm in length along the dorsal aspect of the hallux from the base to just proximal to the eponychium.  Next, the incision was deepened through the subcutaneous tissue.  A heavy amount of bleeding was encountered.  Therefore, a Penrose drain was applied at the tourniquet, which failed.  Next, an Esmarch bandage was used to exsanguinate the distal toes and forefoot and was left in the forefoot to achieve hemostasis.  Any small veins crossing throughout the subcutaneous layer were ligated via electrocautery.  Next, the medial and lateral margins of the incision were under marked with a sharp dissection down to the level of the long extension tendon.  The long extensor tendon was thickened and overall exhibited signs of hypertrophy.  The transverse incision through the long extensor tendon was made with a #15 blade.  Immediately upon entering the joint, yellow discolored fluid was drained from the interphalangeal joint.  Next, the extensor tendon was peeled dorsally and distally off the bone.  Immediately the head of the proximal phalanx was found to be lytic, disease, friable, crumbly, and there were free fragments of the medial aspect of the bone, the head of the proximal phalanx.  This bone was removed with a sharp dissection.  Next, after adequate exposure was obtained and the collateral ligaments were released off the head of proximal phalanx, a sagittal saw was used to resect the approximately one-half of the proximal phalanx.  This was passed off as the infected bone specimen for microbiology and pathology.  Next, the base of the distal phalanx was exposed with sharp dissection and a rongeur was used to remove soft crumbly diseased medial and plantar aspect at the base of distal phalanx.  Next, there was diseased soft tissue envelope around the bone, which was also resected to good healthy tissue margins.  The pulse lavage was used to flush the wound with 1000 cc of gentamicin-impregnated saline.  Next, cleaned instruments were used to take a proximal section of proximal phalanx to label a clean margin.  This bone was found to be hard and healthy appearing.  The wound after irrigation was free of all debris and infected tissue.  Therefore anaerobic and aerobic cultures were taken and sent to microbiology.  Next, OsteoSet beads, tobramycin-impregnated, were placed.  Six beads were placed in the wound.  Next, the extensor tendon was re-approximated with #3-0 Vicryl.  The subcutaneous layer was closed with #4-0 Vicryl in a simple interrupted technique.  Next, the skin was closed with #4-0 nylon in a horizontal mattress technique.,The Esmarch bandage was released and immediate hyperemic flush was noted at the digits.  A standard postoperative dressing was applied consisting of 4 x 4s, Betadine-soaked #0-1 silk, Kerlix, Kling, and a loosely applied Ace wrap.  The patient tolerated the above anesthesia and procedure without complications.  He was transported via a cart to the Postanesthesia Care Unit.  His vitals signs were stable and vascular status was intact.  He was given a medium postop shoe that was well-formed and fitting.  He is to elevate his foot, but not apply ice.  He is to follow up with Dr. X.  He was given emergency contact numbers.  He is to continue the Vicodin p.r.n. pain that he was taking previously for his shoulder pain and has enough of the medicine at home.  The patient was discharged in stable condition.
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DESCRIPTION: Resection of infected bone, left hallux, proximal phalanx, and distal phalanx.  Osteomyelitis, left hallux.

podiatry, osteomyelitis, proximal phalanx, distal phalanx, infected bone, proximal, bone, phalanx, healing, hallux, infected, tissue, distal,

The situation involves a surgical procedure to address chronic osteomyelitis in a 77-year-old male patient. While the surgery itself is not routine, it deals with a condition that has been persistent for nearly a decade, treatment-resistant through antibiotics, and involves significant patient counseling about consequences like a 'floppy tail.' The stakes are moderate because, although not life-threatening, it involves managing chronic infection and restoring patient quality of life. The decision to avoid amputation also indicates a careful balance of patient preferences and medical judgment. However, it is still a complex and significant intervention for the patient's mobility and comfort post-surgery.


Medical Specialty: Podiatry
Sample Name: Foreign Body Removal - Foot - 1

PREOPERATIVE DIAGNOSES:,1.  Cellulitis with associated abscess, right foot.,2.  Foreign body, right foot.,POSTOPERATIVE DIAGNOSES:,1.  Cellulitis with associated abscess, right foot.,2.  Foreign body, right foot.,PROCEDURE PERFORMED:,1.  Irrigation debridement.,2.  Removal of foreign body of right foot.,ANESTHESIA:,  Spinal with sedation.,COMPLICATIONS:,  None.,ESTIMATED BLOOD LOSS: , Minimal.,GROSS FINDINGS: , Include purulent material from the abscess located in the plantar aspect of the foot between the third and fourth metatarsal heads.,HISTORY OF PRESENT ILLNESS: , The patient is a 61-year-old Caucasian male with a history of uncontrolled diabetes mellitus.  The patient states that he was working in his garage over the past few days when he noticed some redness and edema in his right foot.  He notes some itching as well as increasing pain and redness in the right foot and presented to ABCD General Hospital Emergency Room.  He was evaluated by the Emergency Room staff as well as the medical team and the Department of Orthopedics.  It was noted upon x-ray a foreign body in his foot and he had significant amount of cellulitis as well ________ right lower extremity.  After a long discussion held with the patient, it was elected to proceed with irrigation debridement and removal of the foreign body.,PROCEDURE: , After all potential complications, risks, as well as anticipated benefits of the above-named procedures were discussed at length with the patient, informed consent was obtained.  The operative extremity was then confirmed with the patient, operative surgeon, the Department of Anesthesia and nursing staff.  The patient was then transferred to preoperative area to Operative Suite #5 and placed on the operating table in supine position.  All bony prominences were well padded at this time.  The Department of Anesthesia was administered spinal anesthetic to the patient.  Once this anesthesia was obtained, the patient's right lower extremity was sterilely prepped and draped in the usual sterile fashion.  Upon viewing of the plantar aspect of the foot, there was noted to be a swollen ecchymotic area with a small hole in it, which purulent fluid was coming from.  At this time, after all bony and soft tissue landmarks were identified as well as the localization of the pus, a 2 cm longitudinal incision was made directly over this area, which was located between the second and third metatarsal heads.  Upon incising this, there was a foul smelling purulent fluid, which flowed from this region.  Aerobic and anaerobic cultures were taken as well as gram stain.  The area was explored and it ________ to the dorsum of the foot.  There was no obvious joint involvement.  After all loculations were broken, 3 liters antibiotic-impregnated fluid were pulse-evac through the wound.  The wound was again inspected with no more gross purulent or necrotic appearing tissue.  The wound was then packed with an iodoform gauge and a sterile dressing was applied consisting of 4x4s, floss, and Kerlix covered by an Ace bandage.  At this time, the Department of Anesthesia reversed the sedation.  The patient was transferred back to the hospital gurney to Postanesthesia Care Unit.  The patient tolerated the procedure well and there were no complications.,DISPOSITION:  ,The patient will be followed on a daily basis for possible repeat irrigation debridement.
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DESCRIPTION: Cellulitis with associated abscess and foreign body, right foot. Irrigation debridement and removal of foreign body of right foot.  Purulent material from the abscess located in the plantar aspect of the foot between the third and fourth metatarsal heads.

podiatry, removal of foreign body, purulent material, metatarsal, cellulitis, abscess, kerlix, foreign body, foot, irrigation, debridement, purulent,

The situation involves a medical procedure for a patient with a foreign body in the foot, accompanied by cellulitis and an abscess, particularly in a patient with uncontrolled diabetes mellitus. Diabetes can significantly complicate wound healing and infection management, increasing the risks of delayed recovery or more serious complications like sepsis if not properly managed. While the procedure itself (irrigation, debridement, and foreign body removal) is not highly complex, the patient's condition (uncontrolled diabetes) elevates the stakes. Proper management is crucial to prevent further complications that could lead to more severe health outcomes. Therefore, while not emergency high-stakes, the situation is still moderately high-stakes due to the diabetic factor.


Medical Specialty: Podiatry
Sample Name: Debridement - Foot Ulcer

PREOPERATIVE DIAGNOSES,1.  Left lateral fifth ray amputation site cellulitis with infected left fourth metatarsophalangeal joint.,2.  Osteomyelitis of left distal fifth metatarsal bone at left proximal fourth toe phalanx.,3.  Plantar fascitis of left distal lateral foot.,POSTOPERATIVE DIAGNOSES,1.  Left lateral fifth ray amputation site cellulitis with infected left fourth metatarsophalangeal joint.,2.  Osteomyelitis of left distal fifth metatarsal bone at left proximal fourth toe phalanx.,3.  Plantar fascitis of left distal lateral foot.,OPERATION PERFORMED,1.  Debridement of left lateral foot ulcer with excision of infected and infarcted interosseous space muscle tendons and fat.,2.  Sharp excision of left distal foot plantar fascia.,ANESTHESIA:,  None required.,INDICATIONS:,  The patient is a 51-year-old diabetic female with severe peripheral vascular disease, who has had angioplasties and single perineal artery runoff to the left leg who developed gangrene of her left fifth toe requiring left fifth ray amputation.  She has developed cellulitis of the lateral foot with osteomyelitis and now requires debridement of the local fascitis and necrotic tissue to evaluate for current infectious status and prepare for future amputation.,PROCEDURE IN DETAIL:,  The procedure was performed in the patient's room.  The dressing was removed exposing about a 4 cm x 2.5 cm left distal lateral foot fifth ray amputation open wound.  Distally, there is infarcted left fourth metatarsophalangeal joint capsule, as well as plantar fat below the joint.,She has neuropathy allowing debridement of the tissues.,Using sharp scissors and forceps all the necrotic fat and joint capsule area was easily debrided.  There was complete infarction of the lateral joint capsule and the head of the phalanx, as well as distal metatarsal head were chronically infected.,The wound was packed with 4x4 gauze pads and dry gauze pads were placed between the toes followed by Kerlix roll pad.,The patient suffered no complications from the procedure.
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DESCRIPTION: Debridement of left lateral foot ulcer with excision of infected and infarcted interosseous space muscle tendons and fat.  Sharp excision of left distal foot plantar fascia.

podiatry, plantar fascia, foot ulcer, interosseous, metatarsal, cellulitis, amputation, osteomyelitis, plantar fascitis, joint capsule, ray amputation, debridement, plantar, foot

The situation described involves a patient with multiple serious medical conditions, such as diabetes, severe peripheral vascular disease, and osteomyelitis, all of which are high-risk factors. The procedure described is a debridement of an infected ulcer, which is critical to prevent further infection and potential limb loss. The presence of osteomyelitis (a bone infection) and the ongoing need for potential future amputation suggest a high-stakes context due to the risk of systemic infection, further amputation, or even mortality if not properly managed. While the procedure itself had no complications, the underlying conditions indicate high stakes.


Medical Specialty: Podiatry
Sample Name: Bunionectomy & Akin Osteotomy

PREOPERATIVE DIAGNOSIS: , Bunion, left foot.,POSTOPERATIVE DIAGNOSIS: ,Bunion, left foot.,PROCEDURE PERFORMED:,1.  Bunionectomy with first metatarsal osteotomy base wedge type with internal screw fixation.,2.  Akin osteotomy with internal wire fixation of left foot.,HISTORY: , This 19-year-old Caucasian female presents to ABCD General Hospital with the above chief complaint.  The patient states she has had worsening bunion deformity for as long as she could not remember.  She does have a history of Charcot-Marie tooth disease and desires surgical treatment at this time.,PROCEDURE: , An IV was instituted by the Department of Anesthesia in the preoperative holding area.  The patient was transported to the operating room and placed on operating table in the supine position with a safety belt across her lap.  Copious amounts of Webril were placed on the left ankle followed by a blood pressure cuff.  After adequate sedation by the Department of Anesthesia, a total of 15 cc of 1:1 mixture of 1% lidocaine plain and 0.5% Marcaine plain were injected in a Mayo block type fashion surrounding the lower left first metatarsal.  The foot was then prepped and draped in the usual sterile orthopedic fashion.  The foot was elevated from the operating table and exsanguinated with an Esmarch bandage.  The pneumatic ankle tourniquet was inflated to 250 mmHg and the foot was lowered to the operating field.  The stockinette was reflected, the foot was cleansed with a wet and dry sponge.  Approximately 5 cm incision was made dorsomedially over the first metatarsal.,The incision was then deepened with #15 blade.  All vessels encountered were ligated for hemostasis.  Care was taken to preserve the extensor digitorum longus tendon.  The capsule over the first metatarsal phalangeal then was identified where a dorsal capsular incision was then created down to the level of bone.  Capsule and periosteum was reflected off the first metatarsal head.  At this time, the cartilage was inspected and noted to be white, shiny, and healthy cartilage.  There was noted to be a prominent medial eminence.  Attention was then directed to first interspace where a combination of blunt and sharp dissection was done to perform a standard lateral release.  The abductor tendon attachments were identified and transected.  The lateral capsulotomy was performed.  The extensor digitorum brevis tendon was identified and transected.  Attention was then directed to the prominent medial eminence, which was resected with a sagittal saw.  Intraoperative assessment of pes was performed and pes was noted to be normal.,At this time, a regional incision was carried more approximately about 1.5 cm.  The capsular incision was then extended and the proximal capsule and periosteum were reflected off the first metatarsal.  The first metatarsal cuneiform joint was identified.  A 0.45 K-wire was then inserted into the base of the first metatarsal approximately 1 cm from the first cuneiform joint perpendicular to the weightbearing surface.  This K-wire was used as an access guide for a Juvaro type oblique base wedge osteotomy.  The sagittal saw was then used to creat a closing base wedge osteotomy with the apex being proximal medial.  The osteotomy site was then feathered and tilted with tight estimation of the bony edges.  The cortical hinge was maintained.  A 0.27 x 24 mm screw was then inserted in a standard AO fashion.  At this time, there was noted to be tight compression of the osteotomy site.  A second 2.7 x 16 mm screw was then inserted more distally in the standard AO fashion with compression noted.  The ________ angle was noted to be significantly released.  Reciprocating rasp was then used to smoothen any remaining sharp edges.  The 0.45 k-wire was removed.  The foot was loaded and was noted to fill the remaining abduction of the hallux.  At this time, it was incised to perform an Akin osteotomy.,Original incision was then extended distally approximately 1 cm.  The incision was then deepened down to the level of capsule over the base of the proximal phalanx.  Again care was taken to preserve the extensor digitorum longus tendon.  The capsule was reflected off of the base of the proximal phalanx.  An Akin osteotomy was performed with the apex being lateral and the base being medial.  After where the bone was resected, it was feathered until tight compression was noted without tension at the osteotomy site.  Care was taken to preserve the lateral hinge.  At 1.5 wire passed and a drill was then used to create drill hole proximal and distally to the osteotomy site in order for passage of 28 gauge monofilament wire.  The #28 gauge monofilament wire was passed through the drill hole and tightened down until compression and tight ________ osteotomy site was noted.  The remaining edge of the wire was then buried in the medial most distal drill hole.  The area was then inspected and the foot was noted with significant reduction of the bunion deformity.  The area was then flushed with copious amounts of sterile saline.  Capsule was closed with #3-0 Vicryl followed by subcutaneous closure with #4-0 Vicryl in order to decrease tension of the incision site.  A running #5-0 subcuticular stitch was then performed.  Steri-Strips were applied.  Total of 1 cc dexamethasone phosphate was then injected into the surgical site.  Dressings consisted of Owen silk, 4x4s, Kling, Kerlix.  The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all five digits of the left foot.  Posterior splint was then placed on the patient in the operating room.,The patient tolerated the above procedure and anesthesia well without complications.  The patient was transferred back to the PACU with vital signs stable and vascular status intact to the left foot.  The patient was given postoperative instructions to be strictly nonweightbearing on the left foot.  The patient was given postop pain prescriptions for Vicodin and instructed to take one q.4-6h. p.r.n. for pain as well as Naprosyn 500 mg p.o. q. b.i.d.  The patient is to follow-up with Dr. X in his office in four to five days as directed.
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DESCRIPTION: Bunion, left foot.  Bunionectomy with first metatarsal osteotomy base wedge type with internal screw fixation and Akin osteotomy with internal wire fixation of left foot.

podiatry, bunionectomy, akin osteotomy, internal wire fixation, internal screw fixation, osteotomy, metatarsal, metatarsal osteotomy, extensor digitorum, drill hole, osteotomy site, foot

The situation involves a 19-year-old patient undergoing a surgical procedure for correcting a bunion deformity on the left foot. The surgery includes a bunionectomy, first metatarsal osteotomy, and Akin osteotomy, which are standard procedures with some complexity but are generally not considered life-threatening. While the presence of Charcot-Marie-Tooth disease adds some risk to surgery, this is an elective procedure aimed at improving the patient's quality of life rather than addressing an immediate, life-threatening condition. Therefore, it involves moderate stakes typical of surgical interventions, particularly with the potential for complications associated with anesthesia, surgical site infections, or issues with recovery and rehabilitation.


Medical Specialty: Podiatry
Sample Name: Athlete's Foot

ATHLETE'S FOOT, TINEA PEDIS,, is a very common fungal skin infection of the foot.  It often first appears between the toes.  It can be a one-time occurrence or it can be chronic.  The fungus, known as Trichophyton, thrives under warm, damp conditions so people whose feet sweat a great deal are more susceptible.  It is easily transmitted in showers and pool walkways.  Those people with immunosuppressive conditions, such as diabetes mellitus, are also more susceptible to athlete's foot.,SIGNS AND SYMPTOMS:,*  Itchy feet.,*  White or red and soft scaling on feet, usually in between toes.,*  Small blisters may be present.,*  Bad foot odor.,*  Very rare involvement of hands and simultaneously (called an Id reaction).,TREATMENT:,*  Diagnosis is via symptoms or sometimes by examining skin scrapings under a microscope..  A bacterial infection may also be suspected in which case a skin culture will confirm this.,*  Try a non-prescription antifungal powder or cream available in drugstores; your doctor can prescribe a stronger topical antifungal medication if necessary.,*  Oral antibiotics may be prescribed for a possible bacterial infection.,*  Keep feet as dry as possible! Change socks twice a day if necessary and wear those made of natural fibers, such as cotton.  Go barefoot when you have a chance or wear sandals.  Dry thoroughly in between toes after swimming or bathing.,*  A special powder to absorb moisture on feet is also available in drugstores.  Ask the pharmacist about this.,*  Spray your shower at home with a 10% bleach solution after bathing.  This may help decrease the chance that other family members will be infected.,*  Wear sandals or thongs in public showers and around pools.,*  Keep in mind that it may take up to a month or more to get rid of your athlete's foot.  Be diligent in using the antifungal medication.  Unfortunately, recurrence of athlete's foot is common.  Luckily, the condition does not cause serious problems for the majority of people who have it.,*  Call the office if your athlete's foot spreads or worsens despite treatment.,PLANTAR FASCIAL STRETCHES,1.  Raise toes toward you while bending your ankle as high as you can.,2.  Hold this position for 15 seconds.,3.  Alternate doing this with the opposite foot 10 times.,4.  Perform this exercise 2- 3 times a day.,WOUND CARE INSTRUCTIONS,1.  Clean the area daily with soap and water.,2.  Every day apply a thin coat of polysporin ointment.,3.  Change the dressing daily and keep the area covered with an adhesive bandage until completely healed.,4.  Notify the office if you have any increasing wound pain or any evidence of infection.
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DESCRIPTION: A simple note on Athlete's foot, tinea pedis, a very common fungal skin infection of the foot.

podiatry, tinea pedis, infection, foot, athlete's foot, trichophyton, itchy, athlete's foot tinea pedis, fungal skin infection, fungal, athlete's,

Athlete's foot is a common and generally low-risk fungal infection. While it can be uncomfortable and inconvenient, it typically does not lead to serious health issues for the majority of people, and effective treatments are readily available. It can become more problematic for individuals with certain pre-existing conditions, such as diabetes, due to potential complications, but generally, it is not considered a high-stakes medical issue.


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

Medical Specialty: Podiatry
Sample Name: Bone Removal - Metatarsal Head

PREOPERATIVE DIAGNOSIS: , Tailor's bunion, right foot.,POSTOPERATIVE DIAGNOSIS:  ,Tailor's bunion, right foot.,PROCEDURE PERFORMED: , Removal of bone, right fifth metatarsal head.,ANESTHESIA:  ,TIVA/local.,HISTORY: , This 60-year-old male presents to ABCD Preoperative Holding Area after keeping himself n.p.o., since mid night for surgery on his painful right Tailor's bunion.  The patient has a history of chronic ulceration to the right foot which has been treated on an outpatient basis with conservative methods Dr. X.  At this time, he desires surgical correction as the ulcer has been refractory to conservative treatment.  Incidentally, the ulcer is noninfective and practically healed at this date.  The consent is available on the chart for review and Dr. X has discussed the risks versus benefits of this procedure to the patient in detail.,PROCEDURE IN DETAIL: , After IV was established by the Department of Anesthesia, the patient was taken to the operating room, placed on the operating table in supine position and a safety strap was placed across his waist for his protection.  A pneumatic ankle tourniquet was applied about the right foot over copious amount of Webril for the patient's protection.  After adequate IV sedation was administered by the Department of Anesthesia, a total of 10 cc of 1:1 mixture of 1% lidocaine and 0.5% Marcaine plain were administered into the right fifth metatarsal using a Mayo type block technique.  Next, the foot was prepped and draped in the usual aseptic fashion.  An Esmarch bandage was used to exsanguinate the foot and the pneumatic ankle tourniquet was elevated to 250 mmHg.  The foot was lowered in the operating field and a sterile stockinet was reflected.  The Betadine was cleansed with saline-soaked gauze and dried.  Anesthesia was tested with a one tooth pickup and found to be adequate.  A #10 blade was used to make 3.5 cm linear incision over the fifth metatarsophalangeal joint.  A #15 blade was used to deepen the incision to the subcutaneous layer.  Care was taken to retract the extensor digitorum longus tendon medially and the abductor digiti minimi tendon laterally.  Using a combination of sharp and blunt dissection, the medial and lateral edges of the wound were undermined down to the level of the capsule and deep fascia.  A linear capsular incision was made with a #15 blade down to the bone.  The capsular periosteal tissues were elevated off the bone with a #15 blade.  Metatarsal head was delivered into the wound.  There was hypertrophic exostosis noted laterally as well as a large bursa in the subcuteneous tissue layer.  The ulcer on the skin was approximately 2 x 2 mm, it was partial skin thickness and did not probe.  A sagittal saw was used to resect the hypertrophic lateral eminence.  The hypertrophic bone was split in half and one half was sent to Pathology and the other half was sent to Microbiology for culture and sensitivity.  Next, a reciprocating rasp was used to smoothen all bony surfaces.  The bone stock had an excellent healthy appearance and did not appear to be infected.  Copious amount of sterile gentamicin impregnated saline were used to flush the wound.  The capsuloperiosteal tissues were reapproximated with #3-0 Vicryl in simple interrupted technique.  The subcutaneous layer was closed with #4-0 Vicryl in simple interrupted technique.  Next, the skin was closed with #4-0 nylon in a horizontal mattress suture technique.  A standard postoperative dressing was applied consisting of Betadine-soaked Owen silk, 4x4s, Kerlix, and Kling.  The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted at the digits.  The patient tolerated the above anesthesia and procedure without complications.  He was transported via cart to the Postanesthesia Care Unit with vital signs stable and vascular status intact to the right foot.  He was given a postop shoe and will be full weightbearing.  He has prescription already at home for hydrocodone and does not need to refill.  He is to follow up with Dr. X and was given emergency contact numbers.  He was discharged in stable condition.
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DESCRIPTION: Tailor's bunion, right foot.  Removal of bone, right fifth metatarsal head.

podiatry, pneumatic ankle, metatarsal head, tailor's bunion, head, pneumatic, ulceration, metatarsal, bone

The procedure involved in the case, a bone removal from a metatarsal head due to a non-infected Tailor's bunion with related chronic ulceration, is a common and routine procedure in podiatry. The surgery went smoothly without any complications, the patient was stable post-surgery, and the condition being treated was not life-threatening. The risks were discussed with the patient and appropriate precautions were taken, which further reduces the stakes. Given these factors, the situation does not involve high-risk or life-critical decisions, making it low to moderate stakes.


Medical Specialty: Podiatry
Sample Name: Arthroplasty

PREOPERATIVE DIAGNOSES:,1.  Hammertoe deformity, left fifth digit.,2.  Ulceration of the left fifth digit plantolaterally.,POSTOPERATIVE DIAGNOSIS:,1.  Hammertoe deformity, left fifth toe.,2.  Ulceration of the left fifth digit plantolaterally.,PROCEDURE PERFORMED:,1.  Arthroplasty of the left fifth digit proximal interphalangeal joint laterally.,2.  Excision of plantar ulceration of the left fifth digit 3 cm x 1 cm in size.,OPERATIVE PROCEDURE IN DETAIL: , The patient is a 38-year-old female with longstanding complaint of painful hammertoe deformity of her left fifth toe.  The patient had developed ulceration plantarly after being scheduled for removal of a plantar mass in the same area.  The patient elects for surgical removal of this ulceration and correction of her hammertoe deformity at this time.,After an IV was instituted by the Department of Anesthesia, the patient was escorted to the OR where the patient was placed on the Operating Room table in the supine position.  After adequate amount of IV sedation was administered by Anesthesia Department, the patient was given a digital block to the left fifth toe using 0.5% Marcaine plain with 1% lidocaine plain in 1:1 mixture totaling 6 cc.  Following this, the patient was draped and prepped in a normal sterile orthopedic manner.  An ankle tourniquet was placed on the left ankle and the left foot was elevated and Esmarch bandage applied to exsanguinate the foot.  The ankle tourniquet was then inflated to 230 mmHg and then was brought back down to the level of the table.  The stockinette was then cut and reflected and held in place using towel clamp.,The skin was then cleansed using the wet and dry Ray-Tec sponge and then the plantar lesion was outlined.  The lesion measured 1 cm in diameter at the level of the skin and a 3 cm elliptical incision line was drawn on the surface of the skin in the plantolateral aspect of the left fifth digit.  Then using a fresh #15 blade, skin incision was made.  Following this, the incision was then deepened using a fresh #15 blade down to the level of the subcutaneous tissue.  Using a combination of sharp and blunt dissection, the skin was reflected distally and proximally to the lesion.  The lesion appeared well encapsulated with fibrous tissue and through careful dissection using combination of sharp and drill instrumentation the ulceration was removed in its entirety.  The next further exploration was performed to ensure that no residual elements of the fibrous capsular tissue remained within.  The lesion extended from the level of the skin down to the periosteal tissue of the middle and distal phalanx, however, did not show any evidence of extending beyond the level of a periosteum.  Remaining tissues were inspected and appeared healthy.  The lesion was placed in the specimen container and sent to pathology for microanalysis as well as growth.  Attention was then directed to the proximal interphalangeal joint of the left fifth digit and using further dissection with a #15 blade, the periosteum was reflected off the lateral aspect of the proximal ________ median phalanx.  The capsule was also reflected to expose the prominent lateral osseous portion of this joint.  Using a sagittal saw and #139 blade, the lateral osseous prominence was resected.  This was removed in entirety.  Then using power-oscillating rasp, the sharp edges were smoothed and recontoured to the desirable anatomic condition.  Then the incision and wound was flushed using copious amounts of sterile saline with gentamycin.  Following this, the bone was inspected and appeared to be healthy with no evidence of involvement from the removed aforementioned lesion.,Following this, using #4-0 nylon in a combination of horizontal mattress and simple interrupted sutures, the lesion wound was closed and skin was approximated well without tension to the surface skin.  Following this, the incision site was dressed using Owen silk, 4x4s, Kling, and Coban in a normal fashion.  The tourniquet was then deflated and hyperemia was noted to return to digits one through five of the left foot.  The patient was then escorted from the operative table into the Postanesthesia Care Unit.  The patient tolerated the procedure and anesthesia well and was brought to the Postanesthesia Care Unit with vital signs stable and vascular status intact.  In the recovery, the patient was given a surgical shoe as well as given instructions for postoperative care to include rest ice and elevation as well as the patient was given prescription for Naprosyn 250 mg to be taken three times daily as well as Vicodin ES to be taken q.6h. as needed.,The patient will follow-up on Friday with Dr. X in office for further evaluation.  The patient was also given instructions as to signs of infection and to monitor her operative site.  The patient was instructed to keep daily dressings intact, clean, dry, and to not remove them.
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DESCRIPTION: Hammertoe deformity, left fifth digit and ulceration of the left fifth digit plantolaterally.  Arthroplasty of the left fifth digit proximal interphalangeal joint laterally and excision of plantar ulceration of the left fifth digit 3 cm x 1 cm in size.

podiatry, hammertoe deformity, plantolaterall, ulceration, arthroplasty, plantar ulceration, interphalangeal, painful hammertoe, proximal interphalangeal joint, interphalangeal joint, digit, toe, blade, deformity, incision, hammertoe, lesion

The surgical procedure in question involves the correction of a hammertoe deformity and the excision of an ulcer, which generally are not considered life-threatening conditions. While there are inherent risks associated with any surgery, such as infection or complications from anesthesia, the situation does not present an immediate life-or-death scenario. Conditions like hammertoe and localized ulcerations typically have a relatively straightforward treatment and recovery process. Therefore, it is more of a moderate-stakes situation due to the routine nature of the procedures and the patient's stable condition post-operation.


Medical Specialty: Physical Medicine - Rehab
Sample Name: Therapeutic Recreation Initial Evaluation

HISTORY:,  Patient is a 54-year-old male admitted with diagnosis of CVA with right hemiparesis.,Patient is currently living in ABC with his son as this was closer his to his job.  At discharge, he will live with his spouse in a new job.  The home is single level with no steps.,Prior to admission, his wife reports that he was independent with all activities.  He was working full time for an oil company.,Past medical history includes hypertension and diabetes, mental status, and dysphagia.,Ability to follow instruction/rules:  Not able to identify cognitive status as of yet.,COMMUNICATION SKILLS: , No initiation of conversation.  He answered 1 yes/no question.,PHYSICAL STATUS:,  Fall/safety.  Aspiration precautions.,Endurance:  Ball activities 4 to 5 minutes.  Restorator 25 minutes.  Standing and rolling type of 3 minutes.,LEISURE LIFESTYLE:,Level of participation/activities involved in:  Reading and housework.,INFORMATION OBTAINED:,  Interview, observation, and chart review.,TREATMENT PLAN:  ,Treatment plan and goals were discussed with patient along with identification of results of FUNCTIONAL ASSESSMENT OF CHARACTERISTICS FOR THERAPEUTIC RECREATION identifying need for intervention in the following problem areas:  Patient scored 10/11 in physical domain due to decreased endurance.  He scored 11/11 in the cognitive and social domain.,Patient will attend 1 session per day focusing on:  Endurance activities.,Patient will attend 1-2 group sessions per week focusing on leisure awareness and postdischarge resources.,GOALS:,PATIENT GOALS: , Not able to identify, but cooperative with all activities.  He answered yes that he enjoyed the restorator.,SHORT TERM GOALS/ONE WEEK GOALS:,1.  Patient to increase tolerance for ball activities to 7 minutes.,2.  Patient provided to use the restorator as he enjoys and it is good for endurance.,LONG TERM GOALS:,  Patient to increase standing tolerance, standing leisure activities to 7 to 10 minutes.,Patient has concurred with the above treatment planning goals.
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DESCRIPTION: Therapeutic recreation initial evaluation.  Patient is a 54-year-old male admitted with diagnosis of CVA with right hemiparesis.

physical medicine - rehab, endurance, ball activities, therapeutic recreation, hemiparesis, tolerance, recreation, restorator, leisure, therapeutic,

This situation involves a therapeutic recreation initial evaluation for a patient experiencing significant physical and cognitive challenges following a cerebrovascular accident (CVA or stroke), resulting in right hemiparesis. While the evaluation is crucial for the patient’s rehabilitation and quality of life, the immediate stakes are not life-threatening. It aims to improve the patient’s endurance and reintroduce leisure activities, focusing on enhancing daily living functions. The situation requires professional care and attention but does not involve critical life-or-death decisions.