Medical Specialty: Urology
Sample Name: Cystoprostatectomy

PREOPERATIVE DIAGNOSES:,1.  Clinical stage T2, NX, MX transitional cell carcinoma of the urinary bladder, status post chemotherapy and radiation therapy.,2.  New right hydronephrosis.,POSTOPERATIVE DIAGNOSES:,1.  Clinical stage T4a, N3, M1 transitional cell carcinoma of the urinary bladder, status post chemotherapy and radiation therapy.,2.  New right hydronephrosis.,3.  Carcinoid tumor of the small bowel.,TITLE OF OPERATION: , Exploratory laparotomy, resection of small bowel lesion, biopsy of small bowel mesentery, bilateral extended pelvic and iliac lymphadenectomy (including preaortic and precaval, bilateral common iliac, presacral, bilateral external iliac lymph nodes), salvage radical cystoprostatectomy (very difficult due to previous chemotherapy and radiation therapy), and continent urinary diversion with an Indiana pouch.,ANESTHESIA: , General endotracheal and epidural.,INDICATIONS: , This patient is a 65-year-old white male, who was diagnosed with a high-grade invasive bladder cancer in June 2005.  During the course of his workup of transurethral resection, he had a heart attack when he was taken off Plavix after having had a drug-eluting stent placed in.  He recovered from this and then underwent chemotherapy and radiation therapy with a brief response documented by cystoscopy and biopsy after which he had another ischemic event.  The patient has been followed regularly by myself and Dr. X and has been continuously free of diseases since that time.  In that interval, he had a coronary artery bypass graft and was taken off of Plavix.  Most recently, he had a PET CT, which showed new right hydronephrosis and a followup cystoscopy, which showed a new abnormality in the right side of his bladder where he previously had the tumor resected and treated.  I took him to the operating room and extensively resected this area with findings of a high-grade muscle invasive bladder cancer.  We could not identify the right ureteral orifice, and he had a right ureteral stent placed.  Metastatic workup was negative and Cardiology felt he was at satisfactory medical risk for surgery and he was taken to the operating room this time for planned salvage cystoprostatectomy.  He was interested in orthotopic neobladder, and I felt like that would be reasonable if resecting around the urethra indicated the tissue was healthier.  Therefore, we planned on an Indiana pouch continent cutaneous diversion.,OPERATIVE FINDINGS:  ,On exploration, there were multiple abnormalities outside the bladder as follows:  There were at least three small lesions within the distal small bowel, the predominant one measured about 1.5 cm in diameter with a white scar on the surface.  There were two much smaller lesions also with a small white scar, with very little palpable mass.  The larger of the two was resected and found to be a carcinoid tumor.  There also were changes in the small bowel mesentry that looked inflammatory and biopsies of this showed only fibrous tissue and histiocytes.  The small bowel mesentry was fairly thickened at the base, but no discrete abnormality noted.,Both common iliac and lymph node samples were very thickened and indurated, and frozen section of the left showed cancer cells that were somewhat degenerative suggesting a chemotherapy and radiation therapy effect; viability was unable to be determined.  There was a frozen section of the distal right external iliac lymph node that was negative.  The bladder was very thickened and abnormal suggesting extensive cancer penetrating just under the peritoneal surface.  The bladder was fairly stuck to the pelvic sidewall and anterior symphysis pubis requiring very meticulous resection in order to get it off of these structures.  The external iliac lymph nodes were resected on both sides of the obturator; the lymph packet, however, was very stuck and adherent to the pelvic sidewall, and I elected not to remove that.  The rest of the large bowel appeared normal.  There were no masses in the liver, and the gallbladder was surgically absent.  There was nasogastric tube in the stomach.,OPERATIVE PROCEDURE IN DETAIL: , The patient was brought to the operative suite, and after adequate general endotracheal and epidural anesthesia obtained, having placed in the supine position and flexed over the anterior superior iliac spine, his abdomen and genitalia were sterilely prepped and draped in usual fashion.  The radiologist placed a radial arterial line and an intravenous catheter.  Intravenous antibiotics were given for prophylaxis.  We made a generous midline skin incision from high end of the epigastrium down to the symphysis pubis, deepened through the rectus fascia, and the rectus muscles separated in the midline.  Exploration was carried out with the findings described.  The bladder was adherent and did appear immobile.  Moist wound towels and a Bookwalter retractor was placed for exposure.  We began by assessing the small and large bowel with the findings in the small bowel as described.  We subsequently resected the largest of the lesions by exogenous wedge resection and reanastomosed the small bowel with a two-layer running 4-0 Prolene suture.  We then mobilized the cecum and ascending colon and hepatic flexure after incising the white line of Toldt and mobilized the terminal ileal mesentery up to the second and third portion of the duodenum.  The ureters were carefully dissected out and down deep in the true pelvis.  The right ureter was thickened and hydronephrotic with a stent in place and the left was of normal caliber.  I kept the ureters intact until we were moving the bladder off as described above.  At that point, we then ligated the ureters with the RP-45 vascular load and divided it.,We then established the proximal ____________ laterally to both genitofemoral nerves and resected the precaval and periaortic lymph nodes.  The common iliac lymph nodes remained stuck to the ureter.  Frozen section with the findings described on the left.,I then began the dissection over the right external iliac artery and vein and had a great deal of difficulty dissecting distally.  I was, however, able to establish the distal plane of dissection and a large lymph node was present in the distal external iliac vessels.  Clips were used to control the lymphatics distally.  These lymph nodes were sent for frozen section, which was negative.  We made no attempt to circumferentially mobilize the vessels, but essentially, swept the tissue off of the anterior surface and towards the bladder and then removed it.  The obturator nerve on the right side was sucked into the pelvic sidewall, and I elected not to remove those.  On the left side, things were a little bit more mobile in terms of the lymph nodes, but still the obturator lymph nodes were left intact.,We then worked on the lateral pedicles on both sides and essentially determined that I can take these down.  I then mobilized the later half of the symphysis pubis and pubic ramus to get distal to the apical prostate.  At this point, I scrubbed out of the operation, talked to the family, and indicated that I felt the cystectomy was more palliative than therapeutic, and I reiterated his desire to be free of any external appliance.,I then proceeded to take down the lateral pedicles with an RP-45 stapler on the right and clips distally.  The endopelvic fascia was incised.  I then turned my attention posteriorly and incised the peritoneum overlying the anterior rectal wall and ramus very meticulously dissected the rectum away from the posterior Denonvilliers fascia.  I intentionally picked down those two pedicles lateral to the rectum between the clips and then turned my attention retropubically.  I was able to pass a 0 Vicryl suture along the dorsal venous complex, tied this, and then, sealed and divided the complex with a LigaSure and oversewed it distally with 2-0 Vicryl figure-of-eight stitch.  I then divided the urethra distal to the apex of the prostate, divided the Foley catheter between the clamps and then the posterior urethra.  I then was able to take down the remaining distal attachments of the apex and took the dissection off the rectum, and the specimen was then free of all attachments and handed off the operative field.  The bivalved prostate appeared normal.  We then carefully inspected the rectal wall and noted to be intact.  The wound was irrigated with 1 L of warm sterile water and a meticulous inspection made for hemostasis and a dry pack placed in the pelvis.,We then turned our attention to forming the Indiana pouch.  I completed the dissection of the right hepatic flexure and the proximal transverse colon and mobilized the omentum off of this portion of the colon.  The colon was divided proximal to the middle colic using a GIA-80 stapler.  I then divided the avascular plane of Treves along the terminal ileum and selected a point approximately 15 cm proximal to the ileocecal valve to divide the ileum.  The mesentery was then sealed with a LigaSure device and divided, and the bowel was divided with a GIA-60 stapler.  We then performed a side-to-side ileo-transverse colostomy using a GIA-80 stapler, closing the open end with a TA 60.  The angles were reinforced with silk sutures and the mesenteric closed with interrupted silk sutures.,We then removed the staple line along the terminal ileum, passed a 12-French Robinson catheter into the cecal segment, and plicated the ileum with 3 firings of the GIA-60 stapler.  The ileocecal valve was then reinforced with interrupted 3-0 silk sutures as described by Rowland, et al, and following this, passage of an 18-French Robinson catheter was associated with the characteristic "pop," indicating that we had adequately plicated the ileocecal valve.,As the patient had had a previous appendectomy, we made an opening in the cecum in the area of the previous appendectomy.  We then removed the distal staple line along the transverse colon and aligned the cecal end and the distal middle colic end with two 3-0 Vicryl sutures.  The bowel segment was then folded over on itself and the reservoir formed with 3 successive applications of the SGIA Polysorb-75.  Between the staple lines, Vicryl sutures were placed and the defects closed with 3-0 Vicryl suture ligatures.,We then turned our attention to forming the ileocolonic anastomosis.  The left ureter was mobilized and brought underneath the sigmoid mesentery and brought through the mesentery of the terminal ileum and an end-to-side anastomosis performed with an open technique using interrupted 4-0 Vicryl sutures, and this was stented with a Cook 8.4-French ureteral stent, and this was secured to the bowel lumen with a 5-0 chromic suture.  The right ureter was brought underneath the pouch and placed in a stented fashion with an identical anastomosis.  We then brought the stents out through a separate incision cephalad in the pouch and they were secured with a 2-0 chromic suture.  A 24-French Malecot catheter was placed through the cecum and secured with a chromic suture.  The staple lines were then buried with a running 3-0 Vicryl two-layer suture and the open end of the pouch closed with a TA 60 Polysorb suture.  The pouch was filled to 240 cc and noted to be watertight, and the ureteral anastomoses were intact.,We then made a final inspection for hemostasis.  The cecostomy tube was then brought out to the right lower quadrant and secured to the skin with silk sutures.  We then matured our stoma through the umbilicus.  We removed the plug of skin through the umbilicus and delivered the ileal segment through this.  A portion of the ileum was removed and healthy, well-vascularized tissue was matured with interrupted 3-0 chromic sutures.  We left an 18-French Robinson through the stoma and secured this to the skin with silk sutures.  The Malecot and stents were also secured in a similar fashion.,The stoma was returned to the umbilicus after resecting the terminal ileum.,We then placed a large JP drain into both obturator fossae and brought it up the right lower quadrant.  Rectus fascia was closed with buried #2 Prolene stitch anchoring a new figure of 8 at each end tying the two stitches above and in the middle and underneath the fascia.  Interrupted stitches were placed as well.  The subcutaneous tissue was irrigated and skin closed with surgical clips.  The estimated blood loss was 2500 mL.  The patient received 5 units of packed red blood cells and 4 units of FFP.  The patient was then awakened, extubated, and taken on a stretcher to the recovery room in satisfactory condition.
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DESCRIPTION: Exploratory laparotomy, resection of small bowel lesion, biopsy of small bowel mesentery, bilateral extended pelvic and iliac lymphadenectomy (including preaortic and precaval, bilateral common iliac, presacral, bilateral external iliac lymph nodes), salvage radical cystoprostatectomy (very difficult due to previous chemotherapy and radiation therapy), and continent urinary diversion with an Indiana pouch.

The medical situation described involves a complex and extensive surgical procedure on a 65-year-old male with multiple serious health conditions, including high-grade invasive bladder cancer, carcinoid tumor of the small bowel, previous coronary issues, and challenges from chemotherapy and radiation therapy. The procedure itself is intricate, involving multiple surgical techniques and carries considerable risk, as evidenced by the significant blood loss and the need for multiple blood transfusions. Given the patient's complicated medical history and the severity of his diagnoses, the stakes of the situation are quite high. The outcomes of the surgery could significantly impact the patient's quality of life and survival, making it potentially life-saving but also fraught with risk.


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Medical Specialty: Radiology
Sample Name: Facet Arthrogram & Injection

PREOPERATIVE DIAGNOSIS: , Low Back Syndrome - Low Back Pain.,POSTOPERATIVE DIAGNOSIS: , Same.,PROCEDURE:,1.  Bilateral facet Arthrogram at L34, L45, L5S1.,2.  Bilateral facet injections at L34, L45, L5S1.,3.  Interpretation of radiograph.,ANESTHESIA:  ,IV sedation with Versed and Fentanyl.,ESTIMATED BLOOD LOSS: , None.,COMPLICATIONS:  ,None.,INDICATION: , Pain in the lumbar spine secondary to facet arthrosis that was demonstrated by physical examination and verified with x-ray studies and imaging scans.,SUMMARY OF PROCEDURE: , The patient was admitted to the OR, consent was obtained and signed.  The patient was taken to the Operating room and was placed in the prone position.  Monitors were placed, including EKG, pulse oximeter and blood pressure monitoring.  Prior to sedation vitals signs were obtained and were continuously monitored throughout the procedure for amount of pain or changes in pain, EKG, respiration and heart rate and at intervals of three minutes for blood pressure.  After adequate IV sedation with Versed and Fentanyl the procedure was begun.,The lumbar sacral regions were prepped and draped in sterile fashion with Betadine prep and four sterile towels.,The facets in the lumbar regions were visualized with Fluoroscopy using an anterior posterior view.  A skin wheal was placed with 1% Lidocaine at the L34 facet region on the left.  Under fluoroscopic guidance a 22 gauge spinal needle was then placed into the L34 facet on the left side.  This was performed using the oblique view under fluoroscopy to the enable the view of the "Scotty Dog," After obtaining the "Scotty Dog" view the joints were easily seen.  Negative aspiration was carefully performed to verity that there was no venous, arterial or cerebral spinal fluid flow.  After negative aspiration was verified, 1/8th of a cc of Omnipaque 240 dye was then injected.  Negative aspiration was again performed and 1/2 cc of solution (Solution consisting of 9 cc of 0.5% Marcaine with 1 cc of Triamcinolone) was then injected into the joint.  The needle was then withdrawn out of the joint and 1.5 cc of this same solution was injected around the joint.  The 22-gauge needle was then removed.  Pressure was place over the puncture site for approximately one minute.  This exact same procedure was then repeated along the left-sided facets at L45, and L5S1.  This exact same procedure was then repeated on the right side.  At each level, vigilance was carried out during the aspiration of the needle to verify negative flow of blood or cerebral spinal fluid.,The patient was noted to have tolerated the procedure well without any complications.,Interpretation of the radiograph revealed placement of the 22-gauge spinal needles into the left-sided and right-sided facet joints at, L34, L45, and L5S1.  Visualizing the "Scotty Dog" technique under fluoroscopy facilitated this.  Dye spread into each joint space is visualized.  No venous or arterial run-off is noted.  No epidural run-off is noted.  The joints were noted to have chronic inflammatory changes noted characteristic of facet arthrosis.
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DESCRIPTION: Bilateral facet Arthrogram and injections at L34, L45, L5S1.  Interpretation of radiograph.  Low Back Syndrome - Low Back Pain.

radiology, low back syndrome, low back pain, facet injection, fluoroscopy, iv sedation, spinal fluid, facet arthrogram, aspiration, arthrogram, injection, facet,

The procedure described involves a facet arthrogram and injections to relieve low back pain associated with facet arthrosis. This is a routine and minimally invasive procedure typically used for diagnostic or therapeutic purposes in managing back pain. It was performed with local anesthetic and sedation, with no estimated blood loss and no reported complications, indicating a good safety profile. The stakes are relatively low in terms of immediate life-threatening risks. However, it still requires careful monitoring and technical precision due to the involvement of spinal structures and the use of fluoroscopic guidance.

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Medical Specialty: Surgery
Sample Name: Pyeloplasty - Robotic

PROCEDURES:,1.  Robotic-assisted pyeloplasty.,2.  Anterograde right ureteral stent placement.,3.  Transposition of anterior crossing vessels on the right.,4.  Nephrolithotomy.,DIAGNOSIS:,  Right ureteropelvic junction obstruction.,DRAINS:,1.  Jackson-Pratt drain times one from the right flank.,2.  Foley catheter times one.,ESTIMATED BLOOD LOSS: , Less than 30 cc.,COMPLICATIONS: , None.,SPECIMENS:,1.  Renal pelvis.,2.  Kidney stones.,INDICATIONS:  ,The patient is a 30-year-old Caucasian gentleman with history of hematuria subsequently found to have right renal stones and patulous right collecting system with notable two right crossing renal arteries.  Up on consideration of various modalities and therapy, the patient decided to undergo surgical therapy.,PROCEDURE IN DETAIL:  ,The patient was verified by armband and the procedure being robotic-assisted right pyeloplasty with nephrolithotomy was verified, and the procedure was carried out.  After institution of general endotracheal anesthesia and intravenous preoperative antibiotics, the patient was positioned into the right flank position with his right flank elevated.  Great care was taken to pad all pressure points and a right arm hanger was used.  The patient was flexed slightly, and a kidney rest was used.  Sequential compression devices were also placed.  Next, the patient was prepped and draped in normal sterile fashion with povidone-iodine.  Pneumoperitoneum was obtained by placing a Veress needle in the area of the umbilicus after it passed the water test.  A low pressure, high flow pneumoperitoneum was adequately obtained using CO2 gas.  Next, a 12-mm camera port was placed near the umbilicus.  The camera was inserted, and no bowel injury was seen.  Next, under direct vision flanking 8 mm camera ports, a 12 mm assist port, a 5 mm liver retraction port, and 5 mm assist port were placed.  The robot was docked and the instruments passed through respective checks.  Initial attention was directed to mobilizing the right colon from the abdominal wall totally medially.  Next, the right lateral duodenum was cauterized for further access to the right retroperitoneum.  At this point, the right kidney was in clear view, and the fascia was entered.  Initial attention was directed at careful dissection of the renal pelvis and proximal ureter which was done with a combination of electrocautery and blunt dissection.  It became readily apparent that there were two crossing vessels one in the medial inferior region of the kidney and another one in the most inferior portion of the lower pole.  These arteries were dissected carefully and vessel loops were applied.  Next, a small hole was then made in the renal pelvis using electrocautery and the contents of the renal pelvis were suctioned out.  The pyelotomy was extended so that the renal collecting system could be directly inspected.  Sequentially, each major calyx was inspected under direct vision and irrigated.  A total of four round kidney stones were extracted to be sent for analysis to being satisfied for the patient.  At this point, we directed our attention at the proximal right ureter which was dismembered from the remaining renal pelvis.  The proximal ureter was spatulated using cold scissors.  Next, redundant renal pelvis was excised using cold scissors and sent for permanent section.  We then identified the most inferior/dependent portion of the renal pelvis and placed a heel stitch at this for ureteral-renal pelvis anastomosis in a semi running fashion.  3-0 Monocryl sutures were used to re-anastomose the newly spatulated right ureter to the inferior portion of the renal pelvis.  Next, remainder of the pyelotomy was closed to itself also using 2-0 Monocryl sutures.  Before final stitches were placed, a 6x28 ureteral stent was placed anterograde.  This was accomplished by placing the stents over a guidewire, placing the guidewire under direct vision anterograde through the ureter.  This was done until the proximal end was in the renal pelvis, the guidewire was removed, and good proximal curl was verified by direct vision.  Then, the pyelotomy was completely closed again with 2-0 Monocryl sutures.  Next, attention was directed at transposition of the crossing renal artery by fixing it with Vicryl suture that would impinge less upon the renal pelvis.  Good pulsation was verified by direct vision proximal and distal to these pexy sutures.  Next, Gerota's fascia was reapproximated and closed with Vicryl sutures as was the right peritoneum.  Hemostasis appeared excellent at this point.  There was no obvious urine extravasation.  At this time, the procedure was terminated.  The robot was undocked.  Under direct visualization all 8 and 12 mm ports were closed at the level of the fascia with 0 Vicryl sutures in an interrupted fashion.  Then, all skin port sites were closed with 4-0 Monocryl in a subcuticular fashion and Dermabond and band-aids were applied over this.  Also, notably a Jackson-Pratt drain was placed in the area of the right kidney and additional right flank stab incision.  The patient tolerated the procedure well and no immediate perioperative complication was noted.,DISPOSITION: , The patient was discharged to Post Anesthesia Care Unit and subsequently to genitourinary floor to begin his recovery.
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DESCRIPTION: Right ureteropelvic junction obstruction.  Robotic-assisted pyeloplasty, anterograde right ureteral stent placement, transposition of anterior crossing vessels on the right, and nephrolithotomy.

surgery, pyeloplasty, ureteral stent placement, nephrolithotomy, ureteropelvic junction obstruction, jackson-pratt drain, foley catheter, renal pelvis, kidney stones, monocryl sutures, pelvis, renal, ureteropelvic, sutures,

The situation described involves a complex surgical procedure with robotic assistance, involving multiple steps such as nephrolithotomy, ureteral stent placement, and correcting ureteropelvic junction obstruction. Each step of the procedure has a critical importance to ensure patient safety and successful surgical outcomes, which can strongly affect the patient's health and quality of life. Although there were no complications reported and the estimated blood loss was minimal, the stakes during such a surgical procedure are inherently high due to the precision required and the potential risks involved. Thus, the situation can be considered high-stakes due to the nature of surgical procedures, especially involving critical organs like the kidneys.


Medical Specialty: Neurology
Sample Name: MRI Head

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

MRI Head W&WO Contrast.

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

The MRI report describes findings consistent with chronic small vessel ischemic disease and diffuse cortical volume loss, which are not immediately life-threatening conditions, especially as they are described as mild and consistent with the patient's age. There is no evidence of acute infarction, metastases, or other major neurological concerns that would indicate an immediate or life-threatening situation. While chronic conditions like ischemic changes can have serious long-term implications, the findings in this report suggest a more routine or low-immediacy scenario.


Medical Specialty: Hematology - Oncology
Sample Name: MGUS Followup

CHIEF COMPLAINT: , MGUS.,HISTORY OF PRESENT ILLNESS:,  This is an extremely pleasant 86-year-old gentleman, who I follow for his MGUS.  I initially saw him for thrombocytopenia when his ANC was 1300.  A bone marrow biopsy was obtained.  Interestingly enough, at the time of his bone marrow biopsy, his hemoglobin was 13.0 and his white blood cell count was 6.5 with a platelet count of 484,000.  His bone marrow biopsy showed a normal cellular bone marrow; however, there were 10% plasma cells and we proceeded with the workup for a plasma cell dyscrasia.  All his tests came back as consistent with an MGUS.,Overall, he is doing well.  Since I last saw him, he tells me that he has had onset of atrial fibrillation.  He has now started going to the gym two times per week, and has lost over 10 pounds.  He has a good energy level and his ECOG performance status is 0.  He denies any fever, chills, or night sweats.  No lymphadenopathy.  No nausea or vomiting.  No change in bowel or bladder habits.,CURRENT MEDICATIONS: , Multivitamin q.d., aspirin one tablet q.d., Lupron q. three months, Flomax  0.4 mg q.d., and Warfarin 2.5 mg q.d.,ALLERGIES:  ,No known drug allergies.,REVIEW OF SYSTEMS: , As per the HPI, otherwise negative.,PAST MEDICAL HISTORY:,1.  He is status post left inguinal hernia repair.,2.  Prostate cancer diagnosed in December 2004, which was a Gleason 3+4.  He is now receiving Lupron.,SOCIAL HISTORY: , He has a very remote history of tobacco use.  He has one to two alcoholic drinks per day.  He is married.,FAMILY HISTORY: , His brother had prostate cancer.,PHYSICAL EXAM:,VIT:
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DESCRIPTION: MGUS.  His bone marrow biopsy showed a normal cellular bone marrow; however, there were 10% plasma cells and we proceeded with the workup for a plasma cell dyscrasia.  All his tests came back as consistent with an MGUS.

The situation involves a routine follow-up for a patient with Monoclonal Gammopathy of Undetermined Significance (MGUS), which is a generally stable condition that requires monitoring as it can potentially progress to more serious conditions. The patient also presents with atrial fibrillation, a common heart rhythm disorder that requires management but is not immediately life-threatening if properly managed. The patient's overall health seems stable, with no acute symptoms or complications noted. While there are potential long-term implications if MGUS progresses or if the atrial fibrillation worsens, this specific scenario, as described, involves ongoing management rather than emergency intervention.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Femoral Artery Cannulation & Aortogram

PREOPERATIVE DIAGNOSES: , Angina with severe claudication, coronary artery disease, hypertension, dyslipidemia, heavy tobacco abuse, and PAD.,POSTOPERATIVE DIAGNOSES: , Angina with severe claudication, coronary artery disease, hypertension, dyslipidemia, heavy tobacco abuse, and PAD.  Significant coronary artery disease, very severe PAD.,PROCEDURES PERFORMED:,1.  Right common femoral artery cannulation.,2.  Conscious sedation using IV Versed and IV fentanyl.,3.  Retrograde bilateral coronary angiography.,4.  Abdominal aortogram with pelvic runoff.,5.  Left external iliac angiogram with runoff to the patient's left foot.,6.  Left external iliac angiogram with runoff to the patient's right leg.,7.  Right common femoral artery angiogram runoff to the patient's right leg.,PROCEDURE IN DETAIL:,  The patient was taken to the cardiac catheterization laboratory after having a valid consent.  He was prepped and draped in the usual sterile fashion.,After local infiltration with 2% Xylocaine, the right common femoral artery was entered percutaneously and a 4-French sheath was placed over the artery.  The arterial sheath was flushed throughout the procedure.,Conscious sedation was obtained using IV Versed and IV fentanyl.,With the help of a Wholey wire, a 4-French 4-curve Judkins right coronary artery catheter was advanced into the ascending aorta.  The wire was removed, the catheter was flushed.  The catheter was engaged in the left main.  Injections were performed at the left main in different views.  The catheter was then exchanged for an RCA catheter, 4-French 4-curve which was advanced into the ascending aorta with the help of a J-wire.  The wire was removed, the catheter was flushed.  The catheter was engaged in the RCA.  Injections were performed at the RCA in different views.,The catheter was then exchanged for a 5-French Omniflush catheter, which was advanced into the abdominal aorta with the help of a regular J-wire.  The wire was removed.  The catheter was flushed.  Abdominal aortogram was then performed with runoff to the patient's pelvis.,The Omniflush catheter was then retracted into the aortic bifurcation.  Through the Omniflush catheter, a Glidewire was then advanced distally into the left SFA.  The Omniflush was then removed.  Through the wire, a Royal Flush catheter was then advanced into the left external iliac.  The wire was removed.  Left external iliac angiogram was performed with runoff to the patient's left foot _______ was then performed.  The catheter was then retracted into the left common iliac.  Angiograms were performed of the left common iliac with runoff to the patient's left groin.  The catheter was then positioned at the level of the right common iliac.  Angiogram of the right common iliac with runoff to the patient's right leg was then performed.  The catheter was then removed with the help of a J-wire.  The J-wire was left in the abdominal aorta.  Hand injection was performed of the right common femoral artery in 2 locations with runoff to the patient's right leg.,The wire was then removed.  The arterial sheath was then removed after being flushed.  Hemostasis was obtained using hand compression.,The patient tolerated the procedure well and had no complications.  At the end of the procedure, palpable right common femoral pulses were noted as well as 1+ right PT pulse.,Hemodynamic Findings:,  Aortic pressure 140/70.,ANGIOGRAPHIC FINDINGS: , Left main with calcification 25% to 40% lesion.,The left main is very short.,LAD with calcification 25% to 40% proximal lesion.,D1 has 25% lesion.  No in-stent restenosis was noted in D1.,D2 and D3 are very small with luminal irregularities.,Circumflex artery was diseased throughout the vessel.  The circumflex artery has an ostium of 60% to 75% lesion distally and the circumflex has a 75% lesion.,OM1 has 25% to 40% lesion.  These OMs are small with luminal irregularities.,RCA has 25% to 50% lesion, distally, the RCA has luminal irregularities.,Left ventriculography was not done.,ABDOMINAL AORTOGRAM:,  Right renal artery with luminal irregularities.  Left renal artery with luminal irregularities.  The abdominal aorta has 25% lesion.,Right common iliac has a 25% to 50% lesion as well as a distal 75% lesion.,The right external iliac has a proximal 75% lesion.,The distal part of the right external iliac as well as the right common femoral appears to be occlusive by the 5-French sheath.,The right SFA was visualized, although not very well.,Left common iliac with 25% to 50% lesion.  Left external iliac with 25% to 40% lesion.  Left common femoral with 25% to 40% lesion.  Left SFA with 25% lesion.  Left popliteal with wall luminal irregularities.,Three-vessel runoff is noted at the level of the left knee and at the level of the left ankle.,Conclusions:  Severe coronary artery disease.  Very severe peripheral arterial disease.,PLAN: , Because of the anatomic distribution of the coronary artery disease, for now we will continue medical treatment for CAD.  We will proceed with revascularization of the right external iliac as well as right common femoral.  Discontinue tobacco.
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DESCRIPTION: Right common femoral artery cannulation, cnscious sedation using IV Versed and IV fentanyl, retrograde bilateral coronary angiography, abdominal aortogram with pelvic runoff, left external iliac angiogram with runoff to the patient's left foot, left external iliac angiogram with runoff to the patient's right leg, right common femoral artery angiogram runoff to the patient's right leg.

The situation described involves complex and critical medical procedures for a patient with severe cardiovascular conditions, including significant coronary artery disease and very severe peripheral arterial disease. These conditions pose a high risk to the patient's health and require careful management and precise intervention, underscoring the high-stakes nature of the scenario. The procedures aim to assess and potentially address critical blockages and ensure the patient's condition is stabilized, making the stakes quite high.


Medical Specialty: Surgery
Sample Name: ORIF - Fifth Metatarsal

PREOPERATIVE DIAGNOSIS: , Fractured right fifth metatarsal.,POSTOPERATIVE DIAGNOSIS: , Fractured right fifth metatarsal.,PROCEDURE PERFORMED:,1.  Open reduction and internal screw fixation right fifth metatarsal.,2.  Application of short leg splint.,ANESTHESIA:,  TIVA/local.,HISTORY: , This 32-year-old female presents to Preoperative Holding Area after keeping herself n.p.o., since mid night for open reduction and internal fixation of a fractured right fifth metatarsal.  The patient relates that approximately in mid-June that she was working as a machinist at Detroit Diesel and dropped a large set of tools on her right foot.  She continued to walk on the foot and found nothing was wrong despite the pain.  She was recently seen by Dr. X and was referred to Dr. Y for surgery.  The risks versus benefits of the procedure had been explained to the patient in detail by Dr. Y.  The consent is available on the chart for review.  The urine beta was taken in the preoperative area and was negative.,PROCEDURE IN DETAIL:  ,After IV was established by the Department of Anesthesia, the 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 her waist for her protection.  Copious amounts of Webril were applied about the right ankle and a pneumatic ankle tourniquet was applied.  After adequate IV sedation was administered by the Department of Anesthesia, a total of 10 cc of 0.5% Marcaine plain was used to perform an infiltrative type block to the right fifth metatarsal area of the right foot.  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 operative field and a sterile stocking was reflected.  Attention was directed to the right fifth metatarsal base.  The Xi-scan and fluoroscopic unit was used to visualize the fractured fifth metatarsal.  An avulsion fracture of the right fifth metatarsal base was visualized.  The fracture was linear in nature from distal lateral to proximal medial.  There appeared to be a pseudoarthrosis on the lateral view.  A skin scrub was used to carefully mark out all the landmarks including the peroneus longus and brevis tendons in the fifth metatarsal and the sural nerve.  A linear incision was created with a #10 blade.  A #15 blade was used to deepen the incision through the subcutaneous tissue.  All small veins traversing the subcutaneous tissue were ligated with electrocautery.  Next, using combination of sharp and blunt dissection, the deep fascia was reached.  Next a linear capsuloperiosteal incision was made down to the bone using a #15 blade.  Next, using a periosteal elevator and a #15 blade, the capsuloperiosteal tissues were stripped from the bone.  The fracture site was not clearly visualized due to bony callus.  A #25 gauge needle was introduced into the fracture site under fluoroscopy.  The fracture site was easily found.  An osteotome was used to separate the pseudoarthrosis.,A curette was used to remove the hypertrophic excessive pseudoarthrotic bone.  Next, a small ball burr was used to resect the remaining hypertrophic bone.  Next, a #1.0 drill bit was used to drill the subchondral bone on either side of the fracture site and a good healthy bleeding bone.  Next, a bone clamp was applied and the fracture was reduced.  Next, a threaded K-wire was thrown from the proximal base of the fifth metatarsal across the fracture site distally.  A #4-0 mm Synthes partially threaded, cannulated 50 mm screw was thrown using standard AO technique from the proximal fifth metatarsal base down the shaft and the fracture site was fixated rigidly.  All this was done under fluoroscopy.  Next, the wound was flushed with copious amounts of sterile saline.  The fracture site was found to have rigid compression.  The hypertrophic bone on the lateral aspect of the metatarsal was reduced with a ball burr and the wound was again flushed.  Next, the capsuloperiosteal tissues were closed with #3-0 Vicryl in a simple interrupted fashion.  A few fibers of the peroneus brevis tendon that were stripped from the base of the proximal phalanx were reattached carefully with Vicryl.  Next, the subcutaneous layer was closed with #4-0 Vicryl in a simple interrupted suture technique.  Next, the skin was closed with #5-0 Prolene in a horizontal mattress technique.  A postoperative fluoroscopic x-ray was taken and the bony alignment was found to be intact and the screw placement had excellent appearance.  A dressing consisting of Owen silk, 4x4s, fluff, and Kerlix were applied.,A sterile stockinet was applied over the foot.  Next, copious amounts of Webril were applied to pad all bony prominences.  The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all digits.  Next, 4-inch, pre-moulded, well-padded posterior splint was applied.  The capillary refill time of the digits was less than three seconds.  The patient tolerated the above anesthesia and procedure without complications.  After anesthesia was reversed, she was transported via cart to the Postanesthesia Care Unit with vital signs stable and vascular status intact to the right foot.  She was given Vicodin 5/500 mg #30 1-2 p.o. q.4-6h. p.r.n., pain, Naprosyn 500 mg p.o. b.i.d. p.c., Keflex 500 mg #30 one p.o. t.i.d., till gone.  She was given standard postoperative instructions to be non-weightbearing and was dispensed with crutches.  She will rest, ice, and elevate her right leg.  She is to follow up in the clinic on 08/26/03 at 10:30 a.m..  She was given emergency contact numbers and will call or return if problems arise earlier.
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DESCRIPTION: Fractured right fifth metatarsal.  Open reduction and internal screw fixation right fifth metatarsal.  Application of short leg splint.

surgery, metatarsal, internal screw fixation, leg splint, fractured right fifth metatarsal, pneumatic ankle tourniquet, ankle tourniquet, metatarsal base, fracture site, fractured, hypertrophic, bernstein, orif

The situation involves a surgical procedure for a fractured fifth metatarsal. The stakes are moderate-to-high due to the invasive nature of surgery, the need for precise execution to avoid complications, and the potential impact on the patient's mobility if not successful. However, it does not involve life-threatening conditions or critical overall health risks typically associated with higher-stakes procedures. Nevertheless, the patient must follow post-operative instructions carefully to ensure proper healing.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Tracheostomy & SCOOP Procedure

PREOPERATIVE DIAGNOSES:,1.  Oxygen dependency.,2.  Chronic obstructive pulmonary disease.,POSTOPERATIVE DIAGNOSES:,1.  Oxygen dependency.,2.  Chronic obstructive pulmonary disease.,PROCEDURES PERFORMED:,1.  Tracheostomy with skin flaps.,2.  SCOOP procedure FastTract.,ANESTHESIA: , Total IV anesthesia.,ESTIMATED BLOOD LOSS: , Minimal.,COMPLICATIONS:  ,None.,INDICATIONS FOR PROCEDURE: , The patient is a 55-year-old Caucasian male with a history of chronic obstructive pulmonary disease and O2 dependency of approximately 5 liters nasal cannula at home.  The patient with extensive smoking history who presents after risks, complications, and consequences of the SCOOP FastTract procedure were explained.,PROCEDURE:,  The patient was brought to operating suite by Anesthesia and placed on the operating table in the supine position.  After this, the patient was then placed under total IV anesthesia and the operating bed was then placed in reverse Trendelenburg.  The patient's sternal notch along with cricoid and thyroid cartilages were noted and palpated and a sternal marker was utilized to mark the cricoid cartilage in the sternal notch.  The midline was also marked and 1% lidocaine with epinephrine 1:100,000 at approximately 4 cc total was then utilized to localize the neck.  After this, the patient was then prepped and draped with Hibiclens.  A skin incision was then made in the midline with a #15 Bard-Parker in a vertical fashion.  After this, the skin was retracted laterally and a small anterior jugular branch was clamped and cross clamped and tied with #2-0 undyed Vicryl ties.  Further bleeding was controlled with monopolar cauterization and attention was then drawn down on to the strap muscles.  The patient's sternohyoid muscle was identified and grasped on either side and the midline raphe was identified.  Cauterization was then utilized to take down the midline raphe and further dissection was utilized with the skin hook and stat clamps.  The anterior aspect of the thyroid isthmus was identified and palpation on the cricoid cartilage was performed.  The cricoid cauterization over the cricoid cartilage was obtained with the monopolar cauterization and blunt dissection then was carried along the posterior aspect of the thyroid isthmus.  Stats were then placed on either side of the thyroid isthmus and the mid portion was bisected with the monopolar cauterization.  After this, the patient's anterior trachea was then identified and cleaned with pusher.  After this, the cricoid cartilage along the first and second tracheal rings was identified.  The cricoid hook was placed and the trachea was brought more anteriorly and superiorly.  After this, the patient's head incision was placed below the second tracheal ring with a #15 Bard-Parker.  After this, the patient had a tracheal punch with the SCOOP FastTract kit to create a small 4 mm punch within the tracheal cartilage.  After this, the patient then had a tracheal stent placed within the tracheal punched lumen and the patient was then had the tracheal stent secured to the neck with a Vicryl strap.  After this, the cricoid hook was removed and the patient then had FiO2 on the monitor noted with pulse oximetry of 100%.  The patient was then turned back to the anesthesia and transferred to the recovery room in stable condition.  The patient tolerated the procedure well and will stay in the hospital for approximately 23 hours.  The patient will have the stent guidewire removed with a scoop catheter 11 cm placed.
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DESCRIPTION: Tracheostomy with skin flaps and SCOOP procedure FastTract.  Oxygen dependency of approximately 5 liters nasal cannula at home and chronic obstructive pulmonary disease.

cardiovascular / pulmonary, oxygen dependency, chronic obstructive pulmonary disease, tracheostomy, scoop procedure, nasal cannula, scoop procedure fasttract, thyroid isthmus, cricoid cartilage, isthmus, oxygen, dependency, scoop, cartilages

The situation involves a patient undergoing a tracheostomy and SCOOP procedure because of chronic obstructive pulmonary disease and oxygen dependency. Such procedures are generally high-stakes due to the nature of the patient's condition, the risks associated with anesthesia and the potential for complications. However, the documented procedure indicates there were no complications, and the patient is expected to stay in the hospital for 23 hours, suggesting a successful outcome. Despite the inherent risks, the lack of complications and the planned short hospital stay reduce the immediacy and severity of the stakes. Therefore, it is a moderately high-stakes situation.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Gen Med Progress Note - 9

SUBJECTIVE:,  The patient is a 44-year-old white female who is here today with multiple problems.  The biggest concern she has today is her that left leg has been swollen.  It is swollen for three years to some extent, but worse for the past two to three months.  It gets better in the morning when she is up, but then through the day it begins to swell again.  Lately it is staying bigger and she somewhat uncomfortable with it being so large.  The right leg also swells, but not nearly like the left leg.  The other problem she had was she has had pain in her shoulder and back.  These occurred about a year ago, but the pain in her left shoulder is of most concern to her.  She feels like the low back pain is just a result of a poor mattress.  She does not remember hurting her shoulder, but she said gradually she has lost some mobility.  It is hard time to get her hands behind her back or behind her head.  She has lost strength in the left shoulder.  As far as the blood count goes, she had an elevated white count.  In April of 2005, Dr. XYZ had asked Dr. XYZ to see her because of the persistent leukocytosis; however, Dr. XYZ felt that this was not a problem for the patient and asked her to just return here for follow up.  She also complains of a lot of frequency with urination and nocturia times two to three.  She has gained weight; she thinks about 12 pounds since March.  She now weighs 284.  Fortunately, her blood pressure is staying stable.  She takes atenolol 12.5 mg per day and takes Lasix on a p.r.n. basis, but does not like to take it because it causes her to urinate so much.  She denies chest pain, but she does feel like she is becoming gradually more short of breath.  She works for the city of Wichita as bus dispatcher, so she does sit a lot, and just really does not move around much.  Towards the end of the day her leg was really swollen.  I reviewed her lab work.  Other than the blood count her lab work has been pretty normal, but she does need to have a cholesterol check.,OBJECTIVE:,General:  The patient is a very pleasant 44-year-old white female quite obese.,Vital Signs:  Blood pressure:  122/70.  Temperature:  98.6.,HEENT:  Head:  Normocephalic.  Ears:  TMs intact.  Eyes:  Pupils round, and equal.  Nose:  Mucosa normal.  Throat:  Mucosa normal.,Lungs:  Clear.,Heart:  Regular rate and rhythm.,Abdomen:  Soft and obese.,Extremities:  A lot of fluid in both legs, but especially the left leg is really swollen.  At least 2+ pedal edema.  The right leg just has a trace of edema.  She has pain in her low back with range of motion.  She has a lot of pain in her left shoulder with range of motion.  It is hard for her to get her hand behind her back.  She cannot get it up behind her head.  She has pain in the anterior left shoulder in that area.,ASSESSMENT:,1.  Multiple problems including left leg swelling.,2.  History of leukocytosis.,3.  Joint pain involving the left shoulder, probably impingement syndrome.,4.  Low back pain, chronic with obesity.,5.  Obesity.,6.  Frequency with urination.,7.  Tobacco abuse.,PLAN:,1.  I will schedule for a venous Doppler of the left leg and will have her come back in the morning for a CBC and a metabolic panel.  We will start her on Detrol 0.4 mg one daily and also started on Mobic 15 mg per day.,2.  Elevate her leg as much as possible and wear support hose if possible.  Keep her foot up during the day.  We will see her back in two weeks.  We will have the results of the Doppler, the lab work and see how she is doing with the Detrol and the joint pain.  If her shoulder pain is not any better, we probably should refer her on over to orthopedist.  We did do x-rays of her shoulder today that did not show anything remarkable.  See her in two weeks or p.r.n.
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DESCRIPTION: Multiple problems including left leg swelling, history of leukocytosis, joint pain left shoulder, low back pain, obesity, frequency with urination, and tobacco abuse.

soap / chart / progress notes, leg swelling, leukocytosis, joint pain, left shoulder, low back pain, obesity, frequency with urination, tobacco abuse, multiple problems, blood count, blood pressure, leg, shoulder, tobacco, swelling, weight

The patient's medical situation, while complex due to multiple issues like leg swelling, leukocytosis, joint pain, and obesity, does not appear immediately life-threatening based on the progress notes. There are plans for follow-up, diagnostics, and interventions, which the physician seems to manage with a routine approach. However, issues such as the leg swelling, which could potentially relate to circulatory problems, and the elevated white blood count, deserve attention. These could lead to more serious complications if unaddressed, but currently, the stakes do not appear extremely high due to the managed approach and planned follow-ups.


Medical Specialty: Surgery
Sample Name: Transpedicular Decompression

PREOPERATIVE DIAGNOSIS: , Foraminal disc herniation of left L3-L4.,POSTOPERATIVE DIAGNOSES:,1.  Foraminal disc herniation of left L3-L4.,2.  Enlarged dorsal root ganglia of the left L3 nerve root.,PROCEDURE PERFORMED:, Transpedicular decompression of the left L3-L4 with discectomy.,ANESTHESIA:,  General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Minimal.,SPECIMEN: , None.,HISTORY: , This is a 55-year-old female with a four-month history of left thigh pain.  An MRI of the lumbar spine has demonstrated a mass in the left L3 foramen displacing the nerve root, which appears to be a foraminal disc herniation effacing the L3 nerve root.  Upon exploration of the nerve root, it appears that there was a small disc herniation in the foramen, but more impressive was the abnormal size of the dorsal root ganglia that was enlarged more medially than laterally.  There was no erosion into the bone surrounding the area rather in the pedicle above or below or into the vertebral body, so otherwise the surrounding anatomy is normal.  I was prepared to do a discectomy and had not consented the patient for a biopsy of the nerve root.  But because of the sequela of cutting into a nerve root with residual weakness and persistent pain that the patient would suffer, at this point I was not able to perform this biopsy without prior consent from the patient.  So, surgery ended decompressing the L3 foramen and providing a discectomy with idea that we will obtain contrasted MRIs in the near future and I will discuss the findings with the patient and make further recommendations.,OPERATIVE PROCEDURE: , The patient was taken to OR #5 at ABCD General Hospital in a gurney.  Department of Anesthesia administered general anesthetic.  Endotracheal intubation followed.  The patient received the Foley catheter.  She was then placed in a prone position on a Jackson table.  Bony prominences were well padded.  Localizing x-rays were obtained at this time and the back was prepped and draped in the usual sterile fashion.  A midline incision was made over the L3-L4 disc space taking through subcutaneous tissues sharply, dissection was then carried out to the left of the midline with lumbodorsal fascia incised and the musculature was elevated in a supraperiosteal fashion from the level of L3.  Retractors were placed into the wound to retract the musculature.  At this point, the pars interarticularis was identified and the facet joint of L2-L3 was identified.  A marker was placed over the pedicle of L3 and confirmed radiographically.  Next, a microscope was brought onto the field.  The remainder of the procedure was noted with microscopic visualization.  A high-speed drill was used to remove the small portions of the lateral aspects of the pars interarticularis.  At this point, soft tissue was removed with a Kerrison rongeur and the nerve root was clearly identified in the foramen.  As the disc space of L3-L4 is identified, there is a small prominence of the disc, but not as impressive as I would expect on the MRI.  A discectomy was performed at this time removing only small portions of the lateral aspect of the disc.  Next, the nerve root was clearly dissected out and visualized, the lateral aspect of the nerve root appears to be normal in structural appearance.  The medial aspect with the axilla of the nerve root appears to be enlarged.  The color of the tissue was consistent with a nerve root tissue.  There was no identifiable plane and this is a gentle enlargement of the nerve root.  There are no circumscribed lesions or masses that can easily be separated from the nerve root.  As I described in the initial paragraph, since I was not prepared to perform a biopsy on the nerve and the patient had not been consented, I do not think it is reasonable to take the patient to this procedure, because she will have persistent weakness and pain in the leg following this procedure.  So, at this point there is no further decompression.  A nerve fork was passed both ventral and dorsal to the nerve root and there was no compression for lateral.  The pedicle was palpated inferiorly and medially and there was no compression, as the nerve root can be easily moved medially.  The wound was then irrigated copiously and suctioned dry.  A concoction of Duramorph and ______ was then placed over the nerve root for pain control.  The retractors were removed at this point.  The fascia was reapproximated with #1 Vicryl sutures, subcutaneous tissues with #2 Vicryl sutures, and Steri-Strips covering the incision.  The patient transferred to the hospital gurney, extubated by Anesthesia, and subsequently transferred to Postanesthesia Care Unit in stable condition.
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DESCRIPTION: Foraminal disc herniation of left L3-L4.  Enlarged dorsal root ganglia of the left L3 nerve root.  Transpedicular decompression of the left L3-L4 with discectomy.

surgery, dorsal root ganglia, nerve root, discectomy, foraminal disc herniation, transpedicular decompression, lateral aspects, disc herniation, nerve, anesthesia, foraminal

The situation involves a surgical procedure, specifically a transpedicular decompression with discectomy, performed to address a foraminal disc herniation at the L3-L4 level and an enlarged dorsal root ganglia. These neurosurgical interventions generally carry significant risk due to potential complications such as nerve damage, persistent pain, or weakness, especially when nerves are involved. Although no complications occurred during this specific procedure and the patient is stable, the stakes are inherently high due to the nature of spinal surgeries and the potential for long-term consequences if complications were to arise. Additionally, the surgeon's decision not to perform a biopsy on the nerve root without patient consent underscores the critical importance of informed consent in managing these risks. Given these factors, it can be concluded that the situation is high-stakes, although the immediate situation was handled without complications.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Diagnostic Laparoscopy - 1

PREOPERATIVE DIAGNOSIS: , Acute abdominal pain, rule out appendicitis versus other.,POSTOPERATIVE DIAGNOSIS:,  Acute pelvic inflammatory disease and periappendicitis.,PROCEDURE PERFORMED: , Diagnostic laparoscopy.,COMPLICATIONS:,  None.,CULTURES:,  Intra-abdominally are done.,HISTORY:  ,The patient is a 31-year-old African-American female patient who complains of sudden onset of pain and has seen in the Emergency Room.  The pain has started in the umbilical area and radiated to McBurney's point.  The patient appears to have a significant pain requiring surgical evaluation.  It did not appear that the pain was pelvic in nature, but more higher up in the abdomen, more towards the appendix.  The patient was seen by Dr. Y at my request in the ER with me in attendance.  We went over the case.  He decided that she should go to the operating room for evaluation and to have appendix evaluated and probably removed.  The patient on ultrasound had a 0.9 cm ovarian cyst on the right side.  The patient's cyst was not completely simple and they are concerns over the possibility of an abnormality.  The patient states that she has had chlamydia in the past, but it was not a pelvic infection more vaginal infection.  The patient has had hospitalization for this.  The patient therefore signed informed in layman's terms with her understanding that perceivable risks and complications, the alternative treatment, the procedure itself and recovery.  All questions were answered.  ,PROCEDURE: ,The patient was seen in the Emergency Room.  In the Emergency Room, there is really no apparent vaginal discharge.  No odor or cervical motion tenderness.  Negative bladder sweep.  Adnexa were without abnormalities.  In the OR, we were able to perform pelvic examination showing a slightly enlarged fibroid uterus about 9 to 10-week size.  The patient had no adnexal fullness.  The patient then underwent an insertion of a uterine manipulator and Dr. X was in the case at that time and he started the laparoscopic process i.e., inserting the laparoscope.  We then observed under direct laparoscopic visualization with the aid of a camera that there was pus in and around the uterus.  The both fallopian tubes were seen.  There did not appear to be hydrosalpinx.  The ovaries were seen.  The left showed some adhesions into the ovarian fossa.  The cul-de-sac had a banded adhesions.  The patient on the right adnexa had a hemorrhagic ovarian cyst, where the cyst was only about a centimeter enlarged.  The ovary did not appear to have pus in it, but there was pus over the area of the bladder flap.  The patient's bowel was otherwise unremarkable.  The liver contained evidence of Fitz-Hugh-Curtis syndrome and prior PID.  The appendix was somewhat adherent into the retrocecal area and to the mid-quadrant abdominal sidewall on the right.  The case was then turned over to Dr. Y who was in the room at that time and Dr. X had left.  The patient's case was turned over to him.  Dr. Y was performed an appendectomy following which cultures and copious irrigation.  Dr. Y was then closed the case.  The patient was placed on antibiotics.  We await the results of the cultures and as well further ______ therapy.,PRIMARY DIAGNOSES:,1.  Periappendicitis.,2.  Pelvic inflammatory disease.,3.  Chronic adhesive disease.
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DESCRIPTION: Diagnostic laparoscopy.   Acute pelvic inflammatory disease and periappendicitis.  The patient appears to have a significant pain requiring surgical evaluation.  It did not appear that the pain was pelvic in nature, but more higher up in the abdomen, more towards the appendix.

obstetrics / gynecology, periappendicitis, pelvic inflammatory disease, chronic adhesive disease, abdominal pain, appendicitis, diagnostic laparoscopy, laparoscopy, pelvic,

The situation involves a medical procedure - diagnostic laparoscopy - being performed in response to acute abdominal pain with a differential diagnosis indicating potential appendicitis or other serious conditions. The findings during the procedure determined acute pelvic inflammatory disease and periappendicitis. Such medical situations involve invasive procedures with risks, the necessity for intra-abdominal cultures, and the potential for significant health outcomes if not addressed, making this high-stakes. Given these medical considerations, the stakes are higher than typical health situations, although it is a controlled environment and there were no immediate complications reported, which slightly moderates the stakes.


Medical Specialty: Diets and Nutritions
Sample Name: Dietary Consult - Gestational Diabetes

SUBJECTIVE:,  This is a 38-year-old female who comes for dietary consultation for gestational diabetes.  Patient reports that she is scared to eat because of its impact on her blood sugars.  She is actually trying not to eat while she is working third shift at Wal-Mart.  Historically however, she likes to eat out with a high frequency.  She enjoys eating rice as part of her meals.  She is complaining of feeling fatigued and tired all the time because she works from 10 p.m. to 7 a.m. at Wal-Mart and has young children at home.  She sleeps two to four hours at a time throughout the day.  She has been testing for ketones first thing in the morning when she gets home from work.,OBJECTIVE:,  Today's weight:  155.5 pounds.  Weight from 10/07/04 was 156.7 pounds.  A diet history was obtained.  Blood sugar records for the last three days reveal the following:  fasting blood sugars 83, 84, 87, 77; two-hour postprandial breakfast 116, 107, 97; pre-lunch 85, 108, 77; two-hour postprandial lunch 86, 131, 100; pre-supper 78, 91, 100; two-hour postprandial supper 125, 121, 161; bedtime 104, 90 and 88.  I instructed the patient on dietary guidelines for gestational diabetes.  The Lily Guide for Meal Planning was provided and reviewed.  Additional information on gestational diabetes was applied.  A sample 2000-calorie meal plan was provided with a carbohydrate budget established.,ASSESSMENT:,  Patient's basal energy expenditure adjusted for obesity is estimated at 1336 calories a day.  Her total calorie requirements, including a physical activity factor as well as additional calories for pregnancy, totals to 2036 calories per day.  Her diet history reveals that she has somewhat irregular eating patterns.  In the last 24 hours when she was working at Wal-Mart, she ate at 5 a.m. but did not eat anything prior to that since starting work at 10 p.m.  We discussed the need for small frequent eating.  We identified carbohydrate as the food source that contributes to the blood glucose response.  We identified carbohydrate sources in the food supply, recognizing that they are all good for her.  The only carbohydrates she was asked to entirely avoid would be the concentrated forms of refined sugars.  In regard to use of her traditional foods of rice, I pulled out a one-third cup measuring cup to identify a 15-gram equivalent of rice.  We discussed the need for moderating the portion of carbohydrates consumed at one given time.  Emphasis was placed at eating with a high frequency with a goal of eating every two to four hours over the course of the day when she is awake.  Her weight loss was discouraged.  Patient was encouraged to eat more generously but with attention to the amount of carbohydrates consumed at a time.,PLAN:,  The meal plan provided has a carbohydrate content that represents 40 percent of a 2000-calorie meal plan.  The meal plan was devised to distribute her carbohydrates more evenly throughout the day.  The meal plan was meant to reflect an example for her eating, while the patient was encouraged to eat according to appetite and not to go without eating for long periods of time.  The meal plan is as follows:  breakfast 2 carbohydrate servings, snack 1 carbohydrate serving, lunch 2-3 carbohydrate servings, snack 1 carbohydrate serving, dinner 2-3 carbohydrate servings, bedtime snack 1-2 carbohydrate servings.  Recommend patient include a solid protein with each of her meals as well as with her snack that occurs before going to sleep.  Encouraged adequate rest.  Also recommend adequate calories to sustain weight gain of one-half to one pound per week.  If the meal plan reflected does not support slow gradual weight gain, then we will need to add more foods accordingly.  This was a one-hour consultation.  I provided my name and number should additional needs arise.
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DESCRIPTION: Dietary consultation for gestational diabetes.

diets and nutritions, blood sugars, fatigued, total calorie, carbohydrate content, consultation for gestational diabetes, dietary consultation, weight gain, gestational diabetes, carbohydrate servings, meal planning, meals, weight, carbohydrate, dietary, servings, planning

Gestational diabetes is a medical condition that affects pregnancy and can have serious implications for both the mother and the unborn child, including the risk of high blood sugar and its potential complications. The patient is experiencing anxiety about her diet, fatigue from a strenuous work and sleep schedule, and is trying to manage her condition through dietary adjustments. Managing gestational diabetes correctly is critical to prevent complications during pregnancy such as preeclampsia, preterm birth, or fetal overgrowth. Hence, this consultation holds considerable importance for the health of both the mother and child.


Medical Specialty: Orthopedic
Sample Name: Carpal Tunnel Release - 1

PREOPERATIVE DIAGNOSIS: , Right carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS: , Right carpal tunnel syndrome.,TITLE OF THE PROCEDURE: , Right carpal tunnel release.,COMPLICATIONS:,  There were no complications during the procedure.,SPECIMEN:  ,The specimen was sent to pathology.,INSTRUMENTS: , All counts were correct at the end of the case and no complications were encountered.,INDICATIONS:  ,This is a 69-year-old female who have been complaining of right hand pain, which was steadily getting worse over a prolonged period of time.  The patient had tried nonoperative therapy, which did not assist the patient.  The patient had previous diagnosis of carpal tunnel and EMG showed compression of the right median nerve.  As a result of these findings, the patient was sent to my office presenting with this history and was carefully evaluated.  On initial evaluation, the patient had the symptomology of carpal tunnel syndrome.  The patient at the time had the risks, benefits, and alternatives thoroughly explained to her.  All questions were answered.  No guarantees were given.  The patient had agreed to the surgical procedure and the postoperative rehabilitation as needed.,DETAILS OF THE PROCEDURE:  ,The patient was brought to the operating room, placed supine on the operating room table, prepped and draped in the sterile fashion and was given sedation.  The patient was then given sedation.  Once this was complete, the area overlying the carpal ligament was carefully injected with 1% lidocaine with epinephrine.  The patient had this area carefully and thoroughly injected with approximately 10 mL of lidocaine with epinephrine and once this was complete, a 15-blade knife was then used to incise the skin opposite the radial aspect of the fourth ray.  Careful dissection under direct visualization was performed through the subcutaneous fat as well as through the palmar fascia.  A Weitlaner retractor was then used to retract the skin and careful dissection through the palmar fascia would then revealed the transverse carpal ligament.  This was then carefully incised using a 15-blade knife and once entry was again into the carpal canal, a Freer elevator was then inserted and under direct visualization, the carpal ligament was then released.  The transverse carpal ligament was carefully released first in the distal direction until palmar fat could be visualized and by palpation no further ligament could be felt.  The area was well hemostased with the 1% lidocaine with epinephrine and both proximal and distal dissection along the nerve was performed.  Visualization of the transverse carpal ligament was maintained with Weitlaner retractor as well as centric.  Both the centric and the Ragnell were used to retract both proximal and distal corners of the incision and the entirety of the area was under direct visualization at all times.  Palmar fascia was released both proximally and distally as well as the transverse carpal ligament.  Direct palpation of the carpal canal demonstrated a full and complete release.  Observation of the median nerve revealed an area of hyperemia in the distal two-thirds of the nerve, which demonstrated the likely area of compression.  Once this was complete, hemostasis was established using bipolar cautery and some small surface bleeders and irrigation of the area was performed and then the closure was achieved with 4-0 chromic suture in a horizontal mattress and interrupted stitch.  Xeroform was then applied to the incision.  A bulky dressing was then applied consisting of Kerlix and Ace wrap, and the patient was taken to the recovery room in stable condition without any complications.
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DESCRIPTION: Right carpal tunnel release.

Right carpal tunnel release.

orthopedic, carpal tunnel syndrome, ace wrap, emg, freer elevator, kerlix, weitlaner retractor, bulky dressing, carpal tunnel, carpal tunnel release, palmar fascia, subcutaneous fat, lidocaine with epinephrine, transverse carpal ligament, carpal ligament, carpal, tunnel, ligament,

The procedure described is a right carpal tunnel release, which is a common orthopedic surgery for treating carpal tunnel syndrome. While it is a surgical procedure, it is generally considered routine and low risk, with a low likelihood of complications when performed correctly. The document indicates that there were no complications during the surgery and the patient was stable post-operation. Therefore, while the procedure is important for the patient's quality of life, it does not typically involve high stakes comparable to more complex surgeries or life-threatening conditions.


Medical Specialty: Urology
Sample Name: Circumcision - 1

CIRCUMCISION - OLDER PERSON,OPERATIVE NOTE:,  The patient was taken to the operating room and placed in the supine position on the operating table.  General endotracheal anesthesia was administered.  The patient was prepped and draped in the usual sterile fashion.  A 4-0 silk suture is used as a stay-stitch of the glans penis.  Next, incision line was marked circumferentially on the outer skin 3 mm below the corona.  The incision was then carried through the skin and subcutaneous tissues down to within a layer of * fascia.  Next, the foreskin was retracted.  Another circumferential incision was made 3 mm proximal to the corona.  The intervening foreskin was excised.  Meticulous hemostasis was obtained with electrocautery.  Next, the skin was reapproximated at the frenulum with a U stitch of 5-0 chromic followed by stitches at 12, 3, and 9 o'clock.  The stitches were placed equal distance among these to reapproximate all the skin edges.  Next, good cosmetic result was noted with no bleeding at the end of the procedure.  Vaseline gauze, Telfa, and Elastoplast dressing was applied.  The stay-stitch was removed and pressure held until bleeding stopped.  The patient tolerated the procedure well and was returned to the recovery room in stable condition.
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DESCRIPTION: Circumcision in an older person

Circumcision in an older person

urology, circumcision, elastoplast, meticulous hemostasis, telfa, vaseline gauze, circumferential incision, corona, cosmetic result, endotracheal anesthesia, foreskin, glans penis, hemostasis, stay stitch, circumferentially, stitchNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.

The procedure described is a circumcision on an older person, which, while generally considered a routine and low-risk surgical procedure, becomes more complex and potentially risky with increasing patient age due to factors like healing time and underlying health conditions. However, the operation is described as having been completed without complications and the patient returning to stable condition, indicating effective management and low immediate risk. The stakes are not extremely high but are elevated due to the age of the patient and potential for complications post-operatively.


Medical Specialty: Surgery
Sample Name: Ruptured Globe Repair - Cornea

PREOPERATIVE DIAGNOSIS:,  Ruptured globe with full-thickness corneal laceration OX.,POSTOPERATIVE DIAGNOSIS: , Ruptured globe with full-thickness corneal laceration OX.,PROCEDURE:  ,Ruptured globe with full-thickness corneal laceration repair OX.,ANESTHESIA:, General,SPECIMENS:,  None.,COMPLICATIONS:, None.,INDICATIONS:, This is a XX-year-old (wo)man with a ruptured globe with full-thickness corneal laceration of the XXX eye.,PROCEDURE:, The risks and benefits of eye surgery were discussed at length with the patient, including bleeding, infection, astigmatism, cataract, re-operation, loss of vision, and loss of the eye. Informed consent was obtained. The patient received IV antibiotics including Ancef and Levaeuin prior to surgery. The patient was brought to the operating room and placud in the supine position, where (s)he wad prepped and draped in the routine fashion. A wire lid speculum was placed to provide exposure and 0.12 forceps and a Superblade were used to create a paracentesis at approximately 11 o'clock. Viscoat was injected through the paracentesis to fill the anterior chamber. The Viscoat cannula was used to sweep the incarcerated iris tissue from the wound. More Viscoat was injected to deepen the anterior chamber. A 10-0 nylon suture was used to place four sutures to close the corneal laceration. BSS was then injected to fill the anterior chamber and a small leak was noted at the inferior end of the wound. A fifth 10-0 nylon suture was then placed. The wound was packed and found to be watertight. The sutures were rotated, the wound was again checked and found to be watertight. A small amount of Viscoat was, again, injected to deepen the anterior chamber and the wound was swept to be sure there was no incarcerated uveal tissue. Several drops were placed in the XXX eye including Ocuflox, Pred Forte, Timolol 0.5%, Alphagan and Trusopt. An eye patch and shield were taped over the XXX eye. The patient was awakened from general anesthesia. (S)he was taken to the recovery area in good condition. There were no complications.
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DESCRIPTION: Ruptured globe with full-thickness corneal laceration repair - Sample/Template.

surgery, ruptured globe, alphagan, bss, ocuflox, pred forte, superblade, timolol, viscoat cannula, anterior chamber, astigmatism, bleeding, cataract, corneal laceration, full-thickness corneal laceration, infection, laceration repair, loss of the eye, loss of vision, paracentesis, re-operation, wire lid speculum, viscoat, corneal, laceration,

The situation describes a surgical procedure to repair a ruptured globe with a full-thickness corneal laceration. This type of injury and surgery is significant because it involves critical and delicate eye structures. The potential implications of the injury, such as loss of vision or even loss of the eye, make it a high-stakes situation. The surgical procedure is intricate and the stakes are high because failures or complications can result in severe consequences for the patient's vision or eye. Unlike routine procedures, the risk of serious, permanent outcomes elevates the stakes significantly.


Medical Specialty: Orthopedic
Sample Name: ORIF & Cervical Fusion

PREOPERATIVE DIAGNOSIS: , Fracture dislocation, C2.,POSTOPERATIVE DIAGNOSIS:  ,Fracture dislocation, C2.,OPERATION PERFORMED,1.  Open reduction and internal fixation (ORIF) of comminuted C2 fracture.,2.  Posterior spinal instrumentation C1-C3, using Synthes system.,3.  Posterior cervical fusion C1-C3.,4.  Insertion of morselized allograft at C1to C3.,ANESTHESIA:,  GETA.,ESTIMATED BLOOD LOSS:,  100 mL.,COMPLICATIONS: , None.,DRAINS: , Hemovac x1.,Spinal cord monitoring is stable throughout the entire case.,DISPOSITION:,  Vital signs are stable, extubated and taken back to the ICU in a satisfactory and stable condition.,INDICATIONS FOR OPERATION:,  The patient is a middle-aged female, who has had a significantly displaced C2 comminuted fracture.  This is secondary to a motor vehicle accident and it was translated appropriately 1 cm.  Risks and benefits have been conferred with the patient as well as the family, they wish to proceed.  The patient was taken to the operating room for a C1-C3 posterior cervical fusion, instrumentation, open reduction and internal fixation.,OPERATION IN DETAIL: , After appropriate consent was obtained from the patient, the patient was wheeled back to the operating theater room #5.  The patient was placed in the usual supine position and intubated and under general anesthesia without any difficulties.  Spinal cord monitoring was induced.  No changes were seen from the beginning to the end of the case.,Mayfield tongues were placed appropriately.  This was placed in line with the pinna of the ear as well as a cm above the tip of the earlobes.  The patient was subsequently rolled onto the fluoroscopic OSI table in the usual prone position with chest rolls.  The patient's Mayfield tongue was fixated in the usual standard fashion.  The patient was subsequently prepped and draped in the usual sterile fashion.  Midline incision was extended from the base of the skull down to the C4 spinous process.  Full thickness skin fascia developed.  The fascia was incised at midline and the posterior elements at C1, C2, C3, as well as the inferior aspect of the occiput was exposed.  Intraoperative x-ray confirmed the level to be C2.,Translaminar screws were placed at C2 bilaterally.  Trajectory was completed with a hand drill and sounded in all four quadrants to make sure there was no violation of pedicles and once this was done, two 3.5 mm translaminar screws were placed bilaterally at C2.  Good placement was seen both in the AP and lateral planes using fluoroscopy.  Facet screws were then placed at C3.  Using standard technique of Magerl, starting in the inferomedial quadrant 14 mm trajectories in the 25-degree caudad-cephalad direction as well as 25 degrees in the medial lateral direction was made.  This was subsequently sounded in all four quadrants to make sure that there is no elevation of the trajectory.  A 14 x 3.5 mm screws were then placed appropriately.  Lateral masteries at C1 endplate were placed appropriately.  The medial and lateral borders were demarcated with a Penfield.  The great occipital nerve was retracted out the way.  Starting point was made with a high-speed power bur and midline and lateral mass bilaterally.  Using a 20-degree caudad-cephalad trajectory as well as 10-degree lateral-to-medial direction, the trajectory was completed in 8 mm increments, this was subsequently sounded in all four quadrants to make sure that there was no violation of the pedicle wall of the trajectory.  Once this was done, 24 x 3.5 mm smooth Schanz screws were placed appropriately.  Precontoured titanium rods were then placed between the screws at the C1, C2, C3 and casts were placed appropriately.  Once this was done, all end caps were appropriately torqued.  This completed the open reduction and internal fixation of the C2 fracture, which showed perfect alignment.  It must be noted that the reduction was partially performed on the table using lateral fluoroscopy prior to the instrumentation, almost reducing the posterior vertebral margin of the odontoid fracture with the base of the C2 access.  Once the screws were torqued bilaterally, good alignment was seen both in the AP and lateral planes using fluoroscopy, this completed instrumentation as well as open reduction and internal fixation of C2.  The cervical fusion was completed by decorticating the posterior elements of C1, C2, and C3.  Once this was done, the morselized allograft 30 mL of cortical cancellous bone chips with 10 mL of demineralized bone matrix was placed over the decorticated elements.  The fascia was closed using interrupted #1 Vicryl suture figure-of-8.  Superficial drain was placed appropriately.  Good alignment of the instrumentation as well as of the fracture was seen both in the AP and lateral planes.  The subcutaneous tissues were closed using a #2-0 Vicryl suture.  The dermal edges were approximated using staples.  The wound was then dressed sterilely using Bacitracin ointment, Xeroform, 4x4s, and tape, and the drain was connected appropriately.  The patient was subsequently released with a Mayfield contraption and rolled on to the stretcher in the usual supine position.  Mayfield tongues were subsequently released.  No significant bleeding was appreciated.  The patient was subsequently extubated uneventfully and taken back to the recovery room in satisfactory and stable condition.  No complications arose.
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DESCRIPTION: Open reduction and internal fixation (ORIF) of comminuted C2 fracture.  Posterior spinal instrumentation C1-C3, using Synthes system.  Posterior cervical fusion C1-C3.  Insertion of morselized allograft at C1to C3.

orthopedic, fracture dislocation, spinal instrumentatio, comminuted, fracture, morselized, allograft, vicryl suture, mayfield tongues, cervical fusion, internal fixation, orif, cervical, fusion, fixation, spinal, reduction, instrumentation,

The case involves a surgical procedure for a significant cervical spine injury, specifically a fracture dislocation of C2 that required open reduction and internal fixation, along with spinal instrumentation and fusion. Cervical spine surgeries are inherently high-stakes due to the proximity to the spinal cord and the potential for significant neurological impact if complications arise. While the patient's condition was stable post-operation, the risks associated with the surgery render the scenario high-stakes.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Holter Monitor Report

INTERPRETATION:,1.  Predominant rhythm is normal sinus rhythm.,2.  No supraventricular arrhythmia.,3.  Frequent premature ventricular contractions.,4.  Trigemini and couplets.,5.  No high-grade atrial ventricular block was noted.,6.  Diary was not kept.,IMPRESSION:,  Frequent premature atrial contractions, couplets, and trigemini.,
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DESCRIPTION: Holter Monitor Report

Holter Monitor Report

cardiovascular / pulmonary, atrial ventricular block, holter monitor report, holter monitor, frequent premature, holter, monitor, rhythm, ventricular, contractions, trigemini, atrial,

The report does not indicate any life-threatening conditions but mentions frequent premature ventricular contractions and other non-life-threatening arrhythmias like couplets and trigemini. These findings require monitoring and might not necessitate immediate intervention, but they can impact long-term cardiovascular health management. The absence of a patient diary limits understanding of symptom correlation. Overall, while important for patient care, the findings in the report do not represent an immediate high-stakes emergency.


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

Medical Specialty: Orthopedic
Sample Name: Lower Extremity Pain

REASON FOR REFERRAL:,  Evaluation for right L4 selective nerve root block.,CHIEF COMPLAINT:,
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DESCRIPTION: Evaluation for right L4 selective nerve root block.

The situation involves evaluating a patient for a right L4 selective nerve root block due to lower extremity pain. This type of procedure is typically performed to manage pain caused by nerve root irritation or compression, which can significantly affect a patient's quality of life. However, while important for the patient's pain management, it is not an emergency and typical in orthopedic practices. Therefore, it can be considered moderate in terms of stakes.


Medical Specialty: Surgery
Sample Name: Knee Arthroscopy - 1

PROCEDURE IN DETAIL: , After written consent was obtained from the patient, the patient was brought back into the operating room and identified.  The patient was placed in the operating room table in supine position and given general anesthetic.,Ancef 1 g was given for infectious prophylaxis.  Once the patient was under general anesthesia, the knee was prepped and draped in usual sterile fashion.  Once the knee was fully prepped and draped, then we made 2 standard portals medial and lateral.  Through the lateral portal, the camera was placed.  Through the medial portal, tools were placed.  We proceeded to examine scarring of the patellofemoral joint.  Then we probed the patellofemoral joint.  A chondroplasty was performed using a shaver.  Then we moved down to the lateral gutter.  Some loose bodies were found using a shaver and dissection.  We moved down the medial gutter.  No plica was found.,We moved into the medial joint; we found that the medial meniscus was intact.  We moved to the lateral joint and found that the lateral meniscus was intact.  Pictures were taken.  We drained the knee and washed out the knee with copious amounts of sterile saline solution.  The instruments were removed.  The 2 portals were closed using 3-0 nylon suture.  Xeroform, 4 x 4s, Kerlix x2, and TED stocking were placed.  The patient was successfully extubated and brought to the recovery room in stable condition.  I then spoke with the family going over the case, postoperative instructions, and followup care.
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DESCRIPTION: Arthroscopic procedure of the knee.

Arthroscopic procedure of the knee.

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

Knee arthroscopy is a common surgical procedure often performed to diagnose or treat knee joint issues. While it involves general anesthesia and thus carries general surgical risks, it is considered a minimally invasive procedure with a high safety profile. The situation described indicates a standard procedure with no complications reported, suggesting it's relatively routine for the surgical team involved. It is not as high-stakes as major surgeries involving critical organs or acute, life-threatening conditions.


Medical Specialty: Neurology
Sample Name: Epidural Hematoma

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

neurology, loss of consciousness, parietal epidural hematoma, parietal epidural, epidural hematoma, consciousness, epidural, hematoma,

The situation involves an 81-year-old patient who sustained a traumatic brain injury resulting in an epidural hematoma after falling down 20 steps. Given the patient's age, medical history, and the nature of the injury (which required a CT scan and transfer to a neurosurgical unit), this is a high-stakes medical situation. An epidural hematoma, if not managed properly, can lead to serious neurological complications or death. Additionally, the patient has a history of atrial fibrillation and prior stroke, adding to the complexity and risk of the case.


Medical Specialty: Neurology
Sample Name: Electroencephalogram

DESCRIPTION OF RECORD:  ,This tracing was obtained utilizing 27 paste-on gold-plated surface disc electrodes placed according to the International 10-20 system.  Electrode impedances were measured and reported at less than 5 kilo-ohms each.,FINDINGS: , In general, the background rhythms are bilaterally symmetrical.  During the resting awake state they are composed of moderate amounts of low amplitude fast activity intermixed with moderate amounts of well-modulated 9-10 Hz alpha activity best seen posteriorly.  The alpha activity attenuates with eye opening.,During some portions of the tracing the patient enters a drowsy state in which the background rhythms are composed predominantly of moderate amounts of low amplitude fast activity intermixed with moderate amounts of low to medium amplitude polymorphic theta activity.,There is no evidence of focal slowing or paroxysmal activity.,IMPRESSION: , Normal awake and drowsy (stage I sleep) EEG for patient's age.
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DESCRIPTION: Normal awake and drowsy (stage I sleep) EEG for patient's age.

neurology, gold-plated surface disc electrodes, paroxysmal activity, eeg, drowsy stage, sleep eeg, stage, sleep, electrodes, awake, moderate, activity

The situation involves reviewing and interpreting the results of an electroencephalogram (EEG), which is a routine and standard procedure in neurology. The findings in this specific example indicate normal EEG results for both the awake and drowsy states, which suggests there are no immediate concerns or abnormal observations that would necessitate urgent or critical action. As such, the stakes are relatively low given that the interpretation confirms normal brain activity.


Medical Specialty: Neurology
Sample Name: Physical Therapy - Brain Tumor Removal

DIAGNOSIS:,  Status post brain tumor removal.,HISTORY:,  The patient is a 64-year-old female referred to physical therapy following complications related to brain tumor removal.  The patient reports that on 10/24/08 she had a brain tumor removed and had left-sided weakness.  The patient was being seen in physical therapy from 11/05/08 to 11/14/08 then she began having complications.  The patient reports that she was admitted to Hospital on 12/05/08.  At that time, they found massive swelling on the brain and a second surgery was performed.  The patient then remained in acute rehab until she was discharged to home on 01/05/09.  The patient's husband, Al, is also present and he reports that during rehabilitation the patient did have a DVT in the left calf that has since been resolved.,PAST MEDICAL HISTORY: , Unremarkable.,MEDICATIONS:  ,Coumadin, Keppra, Decadron, and Glucophage.,SUBJECTIVE: , The patient reports that the pain is not an issue at this time.  The patient states that her primary concern is her left-sided weakness as related to her balance and her walking and her left arm weakness.,PATIENT GOAL:  ,To increase strength in her left leg for better balance and walking.,OBJECTIVE:,RANGE OF MOTION:  Bilateral lower extremities are within normal limits.,STRENGTH:  Bilateral lower extremities are grossly 5/5 with one repetition, except left hip reflexion 4+/5.,BALANCE:  The patient's balance was assessed with a Berg balance test.  The patient has got 46/56 points, which places her at moderate risk for falls.,GAIT:  The patient ambulates with contact guard assist.  The patient ambulates with a reciprocal gait pattern with good bilateral foot clearance.  However, the patient has been reports that with increased fatigue, left footdrop tends to occur.  A 6-minute walk test will be performed at the next visit due to time constraints.,ASSESSMENT: , The patient is a 64-year-old female referred to Physical Therapy status post brain surgery.  Examination indicates deficits in strength, balance, and ambulation.  The patient will benefit from skilled physical therapy to address these impairments.,TREATMENT PLAN: , The patient will be seen three times per week for 4 weeks and then reduce it to two times per week for 4 additional weeks.  Interventions include:,1.  Therapeutic exercise.,2.  Balance training.,3.  Gait training.,4.  Functional mobility training.,SHORT TERM GOAL TO BE COMPLETED IN 4 WEEKS:,1.  The patient is to tolerate 30 repetitions of all lower extremity exercises.,2.  The patient is to improve balance with a score of 50/56 points.,3.  The patient is to ambulate 1000 feet in a 6-minute walk test with standby assist.,LONG TERM GOAL TO BE ACHIEVED IN 8 WEEKS:,1.  The patient is to ambulate independently within her home and standby to general supervision within the community.,2.  Berg balance test to be 52/56.,3.  The patient is to ambulate a 6-minute walk test for 1500 feet independently including safe negotiation of corners and busy areas.,4.  The patient is to demonstrate safely stepping over and around objects without loss of balance.,Prognosis for the above-stated goals is good.  The above treatment plan has been discussed with the patient and her husband.  They are in agreement.
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DESCRIPTION: Status post brain tumor removal.   The patient is a 64-year-old female referred to physical therapy following complications related to brain tumor removal.  She had a brain tumor removed and had left-sided weakness.

The situation involves a patient recovering from a brain tumor removal surgery who is experiencing complications such as left-sided weakness and a history of brain swelling, DVT, and balance issues. This situation requires careful monitoring and rehabilitation to prevent further complications and promote healing. However, it is a follow-up to surgeries that have already been performed and there is a clear treatment and rehabilitation plan in place, indicating that the most critical immediate medical interventions have already been addressed. While it is certainly important for the patient's recovery, it is more about execution of a recovery plan rather than managing an immediate life-threatening condition at this moment.