Medical Specialty: Surgery
Sample Name: Anterior Cervical Discectomy & Fusion - 4

PREOPERATIVE DIAGNOSIS: , Cervical myelopathy, C3-4, secondary to stenosis from herniated nucleus pulposus, C3-4.,POSTOPERATIVE DIAGNOSES: , Cervical myelopathy, C3-4, secondary to stenosis from herniated nucleus pulposus, C3-4.,OPERATIVE PROCEDURES,1.  Anterior cervical discectomy with decompression, C3-4.,2.  Arthrodesis with anterior interbody fusion, C3-4.,3.  Spinal instrumentation using Pioneer 18-mm plate and four 14 x 4.3 mm screws (all titanium).,4.  Implant using PEEK 7 mm.,5.  Allograft using Vitoss.,DRAINS: , Round French 10 JP drain.,FLUIDS: , 1800 mL of crystalloids.,URINE OUTPUT:  ,1000 mL.,SPECIMENS: , None.,COMPLICATIONS:  ,None.,ANESTHESIA: , General endotracheal anesthesia.,ESTIMATED BLOOD LOSS:  ,Less than 100 mL.,CONDITION:  ,To postanesthesia care unit extubated with stable vital signs.,INDICATIONS FOR THE OPERATION:  ,This is a case of a very pleasant 32-year-old Caucasian male who had been experiencing posterior neck discomfort and was shooting basketball last week, during which time he felt a pop.  Since then, the patient started complaining of acute right arm and right leg weakness, which had been progressively worsening.  About two days ago, he started noticing weakness on the left arm.  The patient also noted shuffling gait.  The patient presented to a family physician and was referred to Dr. X for further evaluation.  Dr. X could not attempt to this, so he called me at the office and the patient was sent to the emergency room, where an MRI of the brain was essentially unremarkable as well as MRI of the thoracic spine.  MRI of the cervical spine, however, revealed an acute disk herniation at C3-C4 with evidence of stenosis and cord changes.  Based on these findings, I recommended decompression.  The patient was started on Decadron at 10 mg IV q.6h.  Operation, expected outcome, risks, and benefits were discussed with him.  Risks to include but not exclusive of bleeding and infection.  Bleeding can be superficial, but can compromise airway, for which he has been told that he may be brought emergently back to the operating room for evacuation of said hematoma.  The hematoma could also be an epidural hematoma, which may compress the spinal cord and result in weakness of all four extremities, numbness of all four extremities, and impairment of bowel and bladder function.  Should this happen, he needs to be brought emergently back to the operating room for evacuation of said hematoma.  There is also the risk by removing the hematoma that he can deteriorate as far as neurological condition, but this hopefully with the steroid prep will be prevented or if present will only be transient.  There is also the possibility of infection, which can be superficial and treated with IV and p.o. antibiotics.  However, should the infection be extensive or be deep, he may require return to the operating room for debridement and irrigation.  This may pose a medical problem since in the presence of infection, the graft as well as spinal instrumentation may have to be removed.  There is also the possibility of dural tear with its attendant complaints of headache, nausea, vomiting, photophobia, as well as the development of pseudomeningocele.  This too can compromise airway and may require return to the operating room for repair of the dural tear.  There is also potential risk of injury to the esophagus, the trachea, as well as the carotid.  The patient can also have a stroke on the right cerebral circulation should the plaque be propelled into the right circulation.  The patient understood all these risks together with the risk associated with anesthesia and agreed to have the procedure performed.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room, awake, alert and not in any form of distress.  After smooth induction and intubation, a Foley catheter was inserted.  No monitoring leads were placed.  The patient was then positioned supine on the operating table with the head supported on a foam doughnut and the neck placed on hyperextension with a shoulder roll under both shoulders.  Localizing x-ray verified the marker to be right at the C3-4 interspace.  Proceeded to mark an incision along the anterior border of the sternocleidomastoid with the central point at the area of the marker measuring about 3 cm in length.  The area was then prepped with DuraPrep.,After sterile drapes were laid out, an incision was made using a scalpel blade #10.  Wound edge bleeders were controlled with bipolar coagulation and a hot knife was utilized to cut the platysma in a similar fashion.  The anterior border of the sternocleidomastoid was identified and dissection was carried superior to and lateral to the esophagus and trachea, but medial to the carotid sheath.  The prevertebral fascia was identified.  Localizing x-ray verified another marker to be at the C3-4 interspace.  Proceeded to strip the longus colli muscles off the vertebral body of C3 and C4 and a self-retaining retractor was then laid out.  There was some degree of anterior osteophyte and this was carefully drilled down with a Midas 5-mm bur.  The disk was then cut through the annulus and removal of the disk was done with the use of the Midas 5-mm bur and later a 3-mm bur.  The inferior endplate of C3 and the superior endplate of C4 were likewise drilled out together with posterior inferior osteophyte at the C3 and the posterior superior osteophyte at C4.  There was note of a central disk herniation centrally, but more marked displacement of the cord on the left side.  By careful dissection of this disk, posterior longitudinal ligament was removed and pressure on the cord was removed.  Hemostasis of the epidural bleeders was done with a combination of bipolar coagulation, but we needed to put a small piece of Gelfoam on the patient's left because of profuse venous bleeder.  With this completed, the Valsalva maneuver showed no evidence of any CSF leakage.  A 7-mm implant with its interior packed with Vitoss was then tapped into place.  An 18-mm plate was then screwed down with four 14 x 4.0 mm screws.  The area was irrigated with saline, with bacitracin solution.  Postoperative x-ray showed excellent placement of the graft and spinal instrumentation.  A round French 10 JP drain was laid over the construct and exteriorized though a separate stab incision on the patient's right inferiorly.  The wound was then closed in layers with Vicryl 3-0 inverted interrupted sutures for the platysma, Vicryl 4-0 subcuticular stitch for the dermis and Dermabond.  The catheter was anchored to the skin with a nylon 3-0 stitch.  Dressing was placed only on the exit site of the drain.  C-collar was placed, and the patient was transferred to the recovery awake and moving all four extremities.
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DESCRIPTION: Anterior cervical discectomy with decompression and arthrodesis with anterior interbody fusion.  Spinal instrumentation using Pioneer 18-mm plate and four 14 x 4.3 mm screws (all titanium).

The situation involves a surgical procedure on the cervical spine, which is inherently high-stakes due to the potential risks and consequences associated with spinal surgery. The procedure described includes complex and delicate operations such as decompression, fusion, and spinal instrumentation, each carrying significant risks such as bleeding, infection, and potential damage to the spinal cord or surrounding areas. The stakes are further heightened by the possibility of severe complications like epidural hematoma, dural tear, or injury to vital structures (esophagus, trachea, carotid artery). Furthermore, the surgery aims to address cervical myelopathy, which can significantly impact the patient’s neurological function if not successfully treated. Given these factors, the scenario is critical and high-stakes.


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Medical Specialty: Surgery
Sample Name: Phacoemulsification & Lens Implantation

PREOPERATIVE DIAGNOSIS:,  Cataract, nuclear sclerotic, right eye.,POSTOPERATIVE DIAGNOSIS:,  Cataract, nuclear sclerotic, right eye.,OPERATIVE PROCEDURES: , Phacoemulsification with intraocular lens implantation, right eye.,ANESTHESIA: , Topical tetracaine, intracameral lidocaine, monitored anesthesia care.,IOL: , AMO Model SI40 NB, power *** diopters.,INDICATIONS FOR SURGERY: , This patient has been experiencing difficulty with eyesight regarding activities in their daily life.  There has been a progressive and gradual decline in the visual acuity.  By examination, this was found to be related to cataracts.  The risks, benefits, and alternatives (including observation or spectacles) were discussed in detail.  The patient accepted these risks and elected to proceed with cataract surgery.  All questions were answered and informed consent was obtained.,Questions were answered in personal conference with the patient to ensure that the patient had a good grasp of the operative goals, risks, and alternatives involved as well as the postoperative instructions.  A preoperative surgical history and physical examination was done to ensure that the patient was in optimal general health for cataract surgery.  To minimize and decrease the chance of bacterial infection, the patient was started on a course of antibiotic drops for two days prior to surgery.,DESCRIPTION OF PROCEDURE:  ,The patient was identified and the procedure was verified.  The pupil was dilated per protocol.  The patient was taken to the operating room and placed in a comfortable supine position.  The operative table was placed in Trendelenburg head-up tilt to decrease orbital congestion and posterior vitreous pressure.  The patient was prepped and draped in the usual ophthalmic sterile fashion.  The lids and periorbita were prepped with full-strength Betadine solution with care taken to concentrate on sterilizing the eyelid margins.  The conjunctival cul-de-sac was also prepped in dilute Betadine solution.  The fornices were also prepped.  The drape was done meticulously to ensure complete eyelash inclusion.,An eyelid speculum was placed to separate the eyelids.  A paracentesis site was made.  Intracameral preservative-free lidocaine was injected.  Amvisc Plus was then used to stabilize the anterior chamber.  A 3-mm diamond blade was then used to carefully construct a clear corneal incision in the temporal location.  A 25-gauge pre-bent cystotome was used to begin a capsulorrhexis.  The capsular flap was removed.  A 27-gauge blunt cannula was used for hydrodissection.  The lens was able to be freely rotated within the capsular bag.  Divide-and-conquer technique was used for phacoemulsification.  After four sculpted grooves were made, a bimanual approach with the phacoemulsification tip and Koch spatula was used to separate and crack each grooved segment.  Each of the four nuclear quadrants was phacoemulsified.  Aspiration was used to remove remaining cortex with the I/A handpiece.  Viscoelastic was used to re-inflate the capsular bag.  The intraocular lens was injected into the capsular bag.  The lens was then dialed into position.  The lens was well-centered and stable.  Viscoelastic was aspirated.  BSS was used to re-inflate the anterior chamber to an adequate estimated intraocular pressure along with stromal hydration.  A Weck-Cel sponge was used to check both incision sites for leaks and none were identified.  The incision sites remained well approximated and dry with a well-formed anterior chamber and well-centered intraocular lens.  The eyelid speculum was removed and the patient was cleaned free of Betadine.  Zymar and Pred Forte drops were applied.  A firm eye shield was taped over the operative eye.  The patient was then taken to the Postanesthesia Recovery Unit in good condition having tolerated the procedure well.,Discharge instructions regarding activity restrictions, eye drop use, eye shield/patch wearing, and driving restrictions were discussed.  All questions were answered.  The discharge instructions were also reviewed with the patient by the discharging nurse.  The patient was comfortable and was discharged with followup in 24 hours.
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DESCRIPTION: Cataract, nuclear sclerotic, right eye.  Phacoemulsification with intraocular lens implantation, right eye.

surgery, nuclear sclerotic, diopters, viscoelastic, capsulorrhexis, amvisc plus, lens implantation, intraocular lens, intraocular, topical, cataract, phacoemulsification, lens

The document describes a medical procedure, specifically cataract surgery with phacoemulsification and lens implantation. While this is a common procedure, it involves eye surgery which requires precise execution to avoid complications such as infection, improper lens placement, or vision impairment. The stakes, while not life-threatening, are significant because of the potential impact on the patient's vision and quality of life. Additionally, preoperative and postoperative care are essential to minimize risks and ensure successful outcomes.

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Medical Specialty: Surgery
Sample Name: Meatoplasty Template

OPERATIVE NOTE:  ,The patient was placed in the supine position under general anesthesia, and prepped and draped in the usual manner.  The penis was inspected.  The meatus was inspected and an incision was made in the dorsal portion of the meatus up towards the tip of the penis connecting this with the ventral urethral groove.  This was incised longitudinally and closed transversely with 5-0 chromic catgut sutures.  The meatus was calibrated and accepted the calibrating instrument without difficulty, and there was no stenosis.  An incision was made transversely below the meatus in a circumferential way around the shaft of the penis, bringing up the skin of the penis from the corpora.  The glans was undermined with sharp dissection and hemostasis was obtained with a Bovie.  Using a skin hook, the meatus was elevated ventrally and the glans flaps were reapproximated using 5-0 chromic catgut, creating a new ventral portion of the glans using the flaps of skin.  There was good viability of the skin.  The incision around the base of the penis was performed, separating the foreskin that was going to be removed from the coronal skin.  This was removed and hemostasis was obtained with a Bovie.  0.25% Marcaine was infiltrated at the base of the penis for post-op pain relief, and the coronal and penile skin was reanastomosed using 4-0 chromic catgut.  At the conclusion of the procedure, Vaseline gauze was wrapped around the penis.  There was good hemostasis and the patient was sent to the recovery room in stable condition.
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DESCRIPTION: An example/template for meatoplasty.

An example/template for meatoplasty.

surgery, penis, meatus, urethral groove, corpora, glans, meatoplasty, bovie, chromic, catgut, hemostasisNOTE,: 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.,

This operative note describes a surgical procedure, specifically a meatoplasty, which involves reconstructive surgery of the urinary meatus and related structures on the penis. Surgery is inherently high-stakes due to the potential for complications such as infection, bleeding, inadequate healing, or damage to nearby structures. In this case, general anesthesia is used, indicating a greater degree of risk compared to local anesthesia. The stakes are heightened further because the procedure involves reconstructing tissues in a delicate area, impacting urinary and possibly sexual function which are critical aspects of the patient's well-being. However, this note depicts a standard, planned surgical template without mention of immediate complications, and the patient appears to have been stable post-operation, which mitigates some of the high-stakes nature.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Pre-Eclampsia & Eclampsia

PRE-ECLAMPSIA, is a very serious condition unique to pregnancy in which blood pressure, the kidneys and the central nervous system are compromised.  It usually occurs from the 20th week of pregnancy to 7 days postpartum.  The cause is unknown.  It is also known as pregnancy-induced hypertension or toxemia of pregnancy.,ECLAMPSIA, is the end-stage of the pre-eclampsia process.  The vast majority of women who develop pre-eclampsia are pregnant with their first child and are towards the end of their child-bearing years.  There are identifiable risk factors for developing pre-eclampsia:  family history of pre-eclampsia, previous pregnancy with pre-eclampsia, multiple gestation, and a hydatiform mole (an intrauterine growth that mimics pregnancy).  A chronic high blood pressure and underlying blood vessel disease increases the risk.  Pre-eclampsia ranges from mild to severe to eclampsia as the end-stage.  Untreated pre-eclampsia can result in a stroke, fluid-build up around the lungs, kidney failure, death of baby and death of mother.,SIGNS AND SYMPTOMS:,MILD PRE-ECLAMPSIA:,*  Significant blood pressure increase even if you are still within the normal blood pressure limits.,*  Swelling in the face, hands and feet which worsens in the a.m.,*  Gaining more than a pound a week, especially in the last trimester.,*  Routine prenatal checkup reveals protein in the urine.,*  Seizures are possible.,SEVERE PRE-ECLAMPSIA:,*  More blood pressure increase.,*  Further swelling in face, hands and feet.,*  Visual disturbances.,*  Headache.,*  Irritability.,*  Abdominal pain.,*  Tiredness.,*  Decreased urination.,*  Seizures possible.,*  Nausea and vomiting.,ECLAMPSIA:,*  Symptoms worsen.,*  Seizures.,*  Muscle twitches.,*  Coma.,TREATMENT:,*  Diagnosis - blood tests, urinalysis, blood pressure monitoring.,*  Mild preeclampsia can be treated at home.  Severe symptoms require hospitalization and possible early delivery of the baby, often by cesarean section.,*  Daily weighing.,*  Daily monitoring for protein in urine.,*  Medications to lower blood pressure if preeclampsia is severe.,*  Magnesium sulfate or other anti-seizure drugs may be necessary to prevent seizures.,*  Get lots of rest! Lay on your left side to help circulation.,*  Follow any dietary advice given by your doctor.,*  Get regular prenatal checkups! Eat a nutritious diet and take your vitamin supplements.,*  Never take any medications that are not prescribed or recommended by your physician.,*  Call the office if your headaches become severe, you have visual disturbances or if you gain more than 3 pounds in 24 hours.,RESTRICTING CAFFEINE:,You should reduce your intake of caffeine by cutting back on coffee and other caffeinated beverages like soda.  In addition, you should avoid chocolate that also contains caffeine.,RESTRICTING SALT:,You are to restrict your salt intake by reducing or eliminating table salt from your meals and avoiding foods that are high in salt concentration.  For more information about which foods are high in salt, read the label of any foods you intend to consume and look for sodium content.
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DESCRIPTION: A sample note on pre-eclampsia & eclampsia.

Pre-eclampsia and its progression to eclampsia are significant medical conditions that can have severe consequences for both the mother and the baby, including kidney failure, stroke, or even death. The situation described involves medical decision-making and intervention to manage and prevent these critical outcomes. The stakes are high, as improper management can lead to catastrophic health issues for both parent and child.


Medical Specialty: Orthopedic
Sample Name: Carpal Tunnel Release - 3

PREOPERATIVE DIAGNOSES:,1.  Left carpal tunnel syndrome (354.0).,2.  Left ulnar nerve entrapment at the elbow (354.2).,POSTOPERATIVE DIAGNOSES:,1.  Left carpal tunnel syndrome (354.0).,2.  Left ulnar nerve entrapment at the elbow (354.2).,OPERATIONS PERFORMED:,1.  Left carpal tunnel release (64721).,2.  Left ulnar nerve anterior submuscular transposition at the elbow (64718).,3.  Lengthening of the flexor pronator muscle mass in the proximal forearm to accommodate the submuscular position of the ulnar nerve (25280).,ANESTHESIA: , General anesthesia with intubation.,INDICATIONS OF PROCEDURE: , This patient is insulin-dependant diabetic.  He is also has end-stage renal failure and has chronic hemodialysis.  Additionally, the patient has had prior heart transplantation.  He has been evaluated for ischemic problems to both lower extremities and also potentially to the left upper extremity.  However, it is our contention that this patient's prime problem of the left upper extremity is probably neuropathic ulcers from total lack of sensation along the ulnar border of the left little finger.  These started initially as unrecognized paper cuts.  Additionally, the patient appears to have a neurogenic pain affecting predominantly the areas innovated by the median nerve, but also to the little finger.  Finally, this patient does indeed have occlusive arterial disease to the left upper extremity in that he has a short segment radial artery occlusion and he does appear to have a narrowed segment in the ulnar artery, but the arteriogram shows distal perfusion down the ulnar border of the hand and into the little finger.  Thus, we have planned to proceed first with nerve entrapment releases and potentially at the later date do arterial reconstruction if deemed necessary.  Thirdly, this patient does have chronic distal ischemic problems with evidence of "ping-pong ball sign" due to fat atrophy at the finger tips and some periodic cracking and ulceration at the tips of the fingers.  However, this patient has no clinical sign at all of tissue necrosis at the finger tips at this time.,The patient has also previously had an arteriovenous shunt in the forearm, which has been deactivated within the last 3 weeks.  Thus, we planned to bring this patient to the operating room for left carpal tunnel release as well as anterior submuscular transposition of the ulnar nerve.  This patient had electro diagnostic studies performed, which showed severe involvement of both the ulnar nerve at the elbow and the medial nerve at the carpal tunnel.,DESCRIPTION OF PROCEDURE: , After general anesthesia being induced and the patient intubated, he is given intravenous Ancef.  The entire left upper extremity is prepped with Betadine all the way to the axilla and draped in a sterile fashion.  A sterile tourniquet and webril are placed higher on the arm.  The arm is then exsanguinated with Ace bandage and tourniquet inflated to 250 mmHg.  I started first at the carpal tunnel release and a longitudinal curvilinear incision is made parallel to the thenar crease and stopping short of the wrist flexion crease.  Dissection continued through subcutaneous tissue to the palmer aponeurosis, which is divided longitudinally from distal to proximal.  I next encountered the transverse carpal ligament, which in turn is also divided longitudinally from distal to proximal, and the proximal most division of the transverse carpal ligament is done under direct vision into the distal forearm.  Having confirmed a complete release of the transverse carpal ligament, I next evaluated the contents of the carpal tunnel.  The synovium was somewhat thickened, but not unduly so.  There was some erythema along the length of the median nerve, indicating chronic compression.  The motor branch of the median nerve was clearly identified.  The contents of the carpal canal were retracted in a radial direction and the floor of the canal evaluated and no other extrinsic compressive pathology was identified.  The wound was then irrigated with normal saline and wound edges were reapproximated with interrupted 5-0 nylon sutures.,I next turned my attention to the cubital tunnel problem and a longitudinal curvilinear incision is made on the medial aspect of the arm extending into the forearm with the incision passing directly between the olecranon and the medial epicondyle.  Dissection continues through fascia and then skin clamps are elevated to the level of the fascia on the flexor pronator muscle mass.  In the process of elevating this skin flap I elevated and deactivated shunt together with the skin flap.  I now gained access to the radial border of the flexor pronator muscle mass, dissected down the radial side, until I identified the median nerve.,I turned my attention back to the ulnar nerve and it is located immediately posterior to the medial intramuscular septum in the upper arm, and I dissected it all the way proximally until I encountered the location with ulnar the nerve passed from the anterior to the posterior compartments in the upper portion of the arm.  The entire medial intramuscular septum is now excised.  The ulnar nerve is mobilized between vessel loops and includes with it is accompanying vascular structures.  Larger penetrating vascular tributaries to the muscle ligated between hemoclips.  I continued to mobilize the nerve around the medial epicondyle and then took down the aponeurosis between the two heads of the flexor carpi ulnaris and continued to dissect the nerve between the FCU muscle fibers.  The nerve is now mobilized and I had retained the large muscular branches and dissected them out into the muscle and also proximally using microvascular surgical techniques.  In this way, the nerve was able to be mobilized between vessiloops and easily transposed anterior to the flexor pronator muscle mass in tension free manner.,I now made an oblique division of the entire flexor pronator muscle mass proximally in the forearm and the ulnar nerve was able to be transposed deep to the muscle in a nonkinking and tension-free manner.  Because of the oblique incision into the flexor pronator muscle mass the muscle edges were now able to slide on each other.  So that in effect a lengthening is performed.  Fascial repair is done with interrupted figure-of-eight 0-Ethibond sutures.  I now ranged the arm through the full range of flexion and extension at the elbow and there was no significant kinking on the nerve and there was a tension-free coverage of the muscle without any impingement on the nerve.  The entire arm is next wrapped with a Kerlix wrap and I released the tourniquet and after allowing the reactive hyperemia to subside, I then unwrap the arm and check for hemostasis.  Wound is copiously irrigated with normal saline and then a 15-French Round Blake drainage placed through a separate stab incision and laid along the length of the wound.  A layered wound closure is done with interrupted Vicryl subcutaneously, and a running subcuticular Monocryl to the skin.  A 0.25% plain Marcaine then used to infiltrate all the wound edges to help with post operative analgesia and dressings take the form of Adaptic impregnated Bacitracin ointment, followed by a well-fluffed gauze and a Kerlix dressing and confirming Kerlix and webril, and an above elbow sugar-tong splint is applied extending to the support of the wrist.  Fingers and femoral were free to move.  The splint is well padded with webril and is in turn held in place with Kerlix and Ace bandage.  Meanwhile the patient is awakened and extubated in the operating room and returned to the recovery room in good condition.  Sponge and needle counts reported as correct at the end of the procedure.
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DESCRIPTION: Left carpal tunnel release, left ulnar nerve anterior submuscular transposition at the elbow, lengthening of the flexor pronator muscle mass in the proximal forearm to accommodate the submuscular position of the ulnar nerve.

orthopedic, carpal tunnel syndrome, ace bandage, kerlix, carpal tunnel release, curvilinear incision, flexor pronator muscle, ping-pong ball sign, synovium, ulnar artery, ulnar nerve, ulnar nerve entrapment, pronator muscle mass, transverse carpal, carpal ligament, tunnel release, flexor pronator, pronator muscle, carpal tunnel, tunnel, carpal, nerve, pronator, forearm,

The described surgical case involves a patient with multiple serious health conditions, including insulin-dependent diabetes, end-stage renal failure on chronic hemodialysis, and a history of heart transplantation. This adds significant risk to any surgical procedure. Furthermore, the surgical interventions—carpal tunnel release and ulnar nerve transposition—are complex and involve delicate anatomical structures in a patient with a higher risk of complications. Despite being orthopedic procedures often performed electively, the patient's overall health status makes this a high-stakes situation.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Treadmill Test

REASON FOR EXAMINATION:,  Abnormal EKG.,FINDINGS: , The patient was exercised according to standard Bruce protocol for 9 minutes achieving maximal heart rate of 146 resulting in 85% of age-predicted maximal heart rate.  Peak blood pressure was 132/60.  The patient did not experience any chest discomfort during stress or recovery.  The test was terminated due to leg fatigue and achieving target heart rate.,Electrocardiogram during stress and recovery did not reveal an additional 1 mm of ST depression compared to the baseline electrocardiogram.  Technetium was injected at 5 minutes into stress.,IMPRESSION:,1.  Good exercise tolerance.,2.  Adequate heart rate and blood pressure response.,3.  This maximal treadmill test did not evoke significant and diagnostic clinical or electrocardiographic evidence for significant occlusive coronary artery disease.,
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DESCRIPTION: The patient was exercised according to standard Bruce protocol for 9 minutes.

cardiovascular / pulmonary, ekg, st depression, maximal heart rate, treadmill test, bruce protocol, blood pressure, heart rate, treadmill, electrocardiogram,

The treadmill test described here is a diagnostic tool often used to assess cardiovascular and pulmonary health, particularly to identify any evidence of coronary artery disease. In this case, the findings indicated good exercise tolerance and adequate heart rate and blood pressure response, without revealing significant evidence of occlusive coronary artery disease. The situation does not suggest immediate medical intervention is required since the test did not evoke any significant clinical issues. While diagnostic tests are important for long-term health assessments, the user's findings suggest a relatively low-risk outcome from this particular test.


Medical Specialty: Orthopedic
Sample Name: Slipped Capital Femoral Epiphysis (SCFE)

EXAM: , Two views of the pelvis.,HISTORY:,  This is a patient post-surgery, 2-1/2 months.  The patient has a history of slipped capital femoral epiphysis (SCFE) bilaterally.,TECHNIQUE: , Frontal and lateral views of the hip and pelvis were evaluated and correlated with the prior film dated MM/DD/YYYY.  Lateral view of the right hip was evaluated.,FINDINGS:,  Frontal view of the pelvis and a lateral view of the right hip were evaluated and correlated with the patient's most recent priors dated MM/DD/YYYY.  Current films reveal stable appearing post-surgical changes.  Again demonstrated is a single intramedullary screw across the left femoral neck and head.  There are 2 intramedullary screws through the greater trochanter of the right femur.  There is a lucency along the previous screw track extending into the right femoral head and neck.  There has been interval removal of cutaneous staples and/or surgical clips.  These were previously seen along the lateral aspect of the right hip joint.,Deformity related to the previously described slipped capital femoral epiphysis is again seen.,IMPRESSION:,1.  Stable-appearing right hip joint status-post pinning.,2.  Interval removal of skin staples as described above.
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DESCRIPTION: Frontal and lateral views of the hip and pelvis.

orthopedic, scfe, frontal and lateral views, slipped capital femoral epiphysis, lateral views, slipped, capital, epiphysis, frontal, pelvis, femoral, hip

The situation involves a post-surgical evaluation of a patient who has undergone treatment for bilateral slipped capital femoral epiphysis (SCFE), a condition that can cause hip deformities and requires surgical intervention. The findings indicate stable post-surgical changes, which is positive, but the situation remains moderately concerning due to the nature of the condition and the need for ongoing monitoring to ensure there are no complications like hardware failure, necrosis, or re-slippage. The potential for critical complications is present, so regular follow-up and assessment are necessary, putting this situation at a moderate level of stakes.


Medical Specialty: Surgery
Sample Name: ORIF - 3

PREOPERATIVE DIAGNOSIS (ES):, Left supracondylar, intercondylar distal femur fracture.,POSTOPERATIVE DIAGNOSIS (ES):, Left supracondylar, intercondylar distal femur fracture.,PROCEDURE:, Open reduction internal fixation of the left supracondylar, intercondylar distal femur fracture (27513).,OPERATIVE FINDINGS:, He had intercondylar split, and then he had a medial Hoffa fracture. He also had some comminution of the medial femoral condyle which prohibited an anatomic key between the two segments of the medial condyle.,IMPLANTS:, We used 2.4 and 3.5 cortical screws, as well as a LISS Synthes femoral locking plate.,COMPLICATIONS:, None.,IV FLUIDS:, 2000,ANESTHESIA:, General endotracheal.,ESTIMATED BLOOD LOSS:, 40 mL,URINE OUTPUT:, 650,HISTORY: ,This 45-year-old male had a ground-level fall, sustaining this injury. He was admitted for definitive operative fixation. Risks and benefits were discussed, he agreed to go ahead with the procedure.,DESCRIPTION OF THE OPERATION:, The patient was identified in preop holding, then taken to the operating room. Once adequate anesthesia was obtained, his left lower extremity was prepped and draped in a routine sterile fashion. He was given antibiotics. He placed a traction pin through his proximal tibia, and pulled weight off the end of the bed. I made a midline approach and then did the lateral parapatellar arthrotomy. We excised some of the fat pad to give us better visibility into the notch. We excised a good bit of his synovium and synovial pouch. At this time we were able to identify the fracture fragments. Again, there was an intercondylar split and then two free pieces of the medial condyle. The femur fracture was very distal through the metaphysis. At this time we thoroughly cleaned out all the clot between all the fracture fragments and cleaned the cortical margins.,Next we began the reduction. There was no reduction key between the two segments of the Hoffa fracture. Therefore, we reduced the anterior portion of the medial condyle to the lateral condyle, held it with point-of-reduction clamp and K-wires, and then secured it with 2.4 mini fragment lag screws. Next, with this medial anterior piece in place, we had some contour over the notch with which we were able to reduce the posterior medial Hoffa fragment. This gave us a nice notch contour. Again, there was some comminution laterally so that the fracture between the Hoffa segments did not have a perfect key. Once we had it reduced, based on the notch reduction, we then held it with K-wires. We secured it with two 3.5 cortical screws from the lateral condyle into this posterior segment. We then secured it with 2.4 cortical screws from the anterior medial to the posterior medial segment just subchondral. Then, finally, we secured it with a 3.5 cortical screw from the anterior medial to the posterior medial piece. All screws ran between and out of the notch.,With the condyle now well reduced, we reduced it to the metaphysis. We slid a 13-hole LISS plate submuscularly. We checked on AP and lateral views that showed we had good reduction of the fracture and appropriate plate placement. We placed the tip threaded guidewire through the A-hole of the plate jig and got it parallel to the joint. We then clamped the plate down to the bone. Proximally, we made a stab incision for the trocar at the 13-hole position, placed our tip threaded guidewire in the lateral aspect of the femur, checked it on lateral view, and had it in good position.,With the jig in appropriate position and clamped, we then proceeded to fill the distal locking screws to get purchase into the condyles. We then placed multiple unicortical locking screws in the shaft and metaphyseal segment. Our most proximal screw was proximal to the tip of the prosthesis.,At this time we took the jig off and put the final screw into the A-hole of the plate. We then took final C-arm views which showed we had a good reduction on AP and lateral views, the plate was in good position, we had full range of motion of the knee, and good reduction clinically and radiographically. We then pulse lavaged the knee with 3 liters of fluid. We closed the quad tendon and lateral retinaculum with interrupted 0 Vicryl over a Hemovac drain. Subdermal tissue was closed with 2-0 Vicryl, skin with staples. Sterile dressing and a hinged knee brace were applied. The patient was awakened from anesthesia and taken to Recovery in stable condition.,PLAN:,1. Nonweightbearing for 3 months.,2. CPM for 0 to 90 degrees as tolerated.
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DESCRIPTION: Open reduction internal fixation of the left supracondylar, intercondylar distal femur fracture.

The situation describes a detailed surgical procedure for an open reduction internal fixation (ORIF) of a distal femur fracture, which is a significant orthopedic operation. While the procedure and post-operative recovery have gone smoothly, the stakes involve surgical precision and the potential for complications. Although this case reports no complications, any surgical operation carries inherent risks such as infection, improper healing, or adverse reactions to anesthesia. Moreover, the outcome impacts the patient's mobility and long-term joint function. Considering these factors, this situation involves moderately high stakes in terms of patient health and surgical complexity.


Medical Specialty: Radiology
Sample Name: PET Report - Whole Body Scan

INDICATION: , Lung carcinoma.,Whole body PET scanning was performed with 11 mCi of 18 FDG. Axial, coronal and sagittal imaging was performed over the neck, chest abdomen and pelvis.,FINDINGS:,There is normal physiologic activity identified in the myocardium, liver, spleen, ureters, kidneys and bladder.,There is abnormal FDG-avid activity identified in the posterior left paraspinal region best seen on axial images 245-257 with an SUV of 3.8, no definite bone lesion is identified on the CT scan or the bone scan dated 08/14/2007 (It may be purely lytic).,Additionally there is a significant area of activity corresponding to a mass in the region of the left hilum that is visible on the CT scan with an SUV of 18.1, the adjacent atelectasis as likely post obstructive in nature.,Additionally, although there is no definite lesion identified on CT , there is a tiny satellite nodule in the left upper lobe that is hypermetabolic with an SUV of 5.0. The spiculated density seen in the right upper lobe on the CT scan does not demonstrate FDG activity on this PET scan.,There is a hypermetabolic lymph node identified in the aorta pulmonary window with an SUV of 3.7 in the mediastinum.,IMPRESSION:,No prior PET scans for comparison, there is a large lesion identified in the area of the left hilum with an SUV of 18.1 likely causing the obstructive atelectasis seen on the CT scan.,There is a tiny satellite area of hypermetabolic FDG in the left upper lobe adjacent to the pleura with an SUV of 5.0.,There is a area of hypermetabolic activity in the left paraspinal soft tissues at the level of the lung apices which may represent a focal bone lesion. However no lesion is identified on bone scan or CT scan.,There is a hypermetabolic lymph node identified. The aorta pulmonary window with a corresponding finding on CT scan with an SUV of 3.7.
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DESCRIPTION: Whole body PET scanning.

Whole body PET scanning.

radiology, whole body scan, pet scanning, lung carcinoma, axial, coronal, sagittal, imaging, pet scans, hypermetabolic lymph node, hypermetabolic lymph, lymph node, pulmonary window, ct scan, scan, fdg, pet, suv, ct,

The report indicates possible metastasis in a patient with known lung carcinoma, which signifies a critical stage in cancer management. The identification of hypermetabolic regions may suggest cancer spread, impacting treatment plans significantly, hence high-stakes.


Medical Specialty: Surgery
Sample Name: Nephrectomy - Partial

PREOPERATIVE DIAGNOSIS:,  Left renal mass, 5 cm in diameter.,POSTOPERATIVE DIAGNOSIS:,  Left renal mass, 5 cm in diameter.,OPERATION PERFORMED: , Left partial nephrectomy.,ANESTHESIA: , General with epidural.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , About 350 mL.,REPLACEMENT: , Crystalloid and Cell Savers from the case.,INDICATIONS FOR SURGERY:  ,This is a 64-year-old man with a left renal mass that was confirmed to be renal cell carcinoma by needle biopsy.  Due to the peripheral nature of the tumor located in the mid to lower pole laterally, he has elected to undergo a partial nephrectomy.  Potential complications include but are not limited to,,1.  Infection.,2.  Bleeding.,3.  Postoperative pain.,4.  Herniation from the incision.,PROCEDURE IN DETAIL:,  Epidural anesthesia was administered in the holding area, after which the patient was transferred into the operating room.  General endotracheal anesthesia was administered, after which the patient was positioned in the flank standard position.  A left flank incision was made over the area of the twelfth rib.  The subcutaneous space was opened by using the Bovie.  The ribs were palpated clearly and the fascia overlying the intercostal space between the eleventh and twelfth rib was opened by using the Bovie.  The fascial layer covering of the intercostal space was opened completely until the retroperitoneum was entered.  Once the retroperitoneum had been entered, the incision was extended until the peritoneal envelope could be identified.  The peritoneum was swept medially.  The Finochietto retractor was then placed for exposure.  The kidney was readily identified and was mobilized from outside Gerota's fascia.  The ureter was dissected out easily and was separated with a vessel loop.  The superior aspect of the kidney was mobilized from the superior attachment.  The pedicle of the left kidney was completely dissected revealing the vein and the artery.  The artery was a single artery and was dissected easily by using a right-angle clamp.  A vessel loop was placed around the renal artery.  The tumor could be easily palpated in the lateral lower pole to mid pole of the left kidney.  The Gerota's fascia overlying that portion of the kidney was opened in the area circumferential to the tumor.  Once the renal capsule had been identified, the capsule was scored using a Bovie about 0.5 cm lateral to the border of the tumor.  Bulldog clamp was then placed on the renal artery.  The tumor was then bluntly dissected off of the kidney with a thin rim of a normal renal cortex.  This was performed by using the blunted end of the scalpel.  The tumor was removed easily.  The argon beam coagulation device was then utilized to coagulate the base of the resection.  The visible larger bleeding vessels were oversewn by using 4-0 Vicryl suture.  The edges of the kidney were then reapproximated by using 2-0 Vicryl suture with pledgets at the ends of the sutures to prevent the sutures from pulling through.  Two horizontal mattress sutures were placed and were tied down.  The Gerota's fascia was then also closed by using 2-0 Vicryl suture.  The area of the kidney at the base was covered with Surgicel prior to tying the sutures.  The bulldog clamp was removed and perfect hemostasis was evident.  There was no evidence of violation into the calyceal system.  A 19-French Blake drain was placed in the inferior aspect of the kidney exiting the left flank inferior to the incision.  The drain was anchored by using silk sutures.  The flank fascial layers were closed in three separate layers in the more medial aspect.  The lateral posterior aspect was closed in two separate layers using Vicryl sutures.  The skin was finally reapproximated by using metallic clips.  The patient tolerated the procedure well.
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DESCRIPTION: Left partial nephrectomy due to left renal mass.

surgery, renal mass, bovie, finochietto retractor, gerota's fascia, herniation, bulldog clamp, needle biopsy, nephrectomy, partial nephrectomy, renal cell carcinoma, retroperitoneum, vicryl suture, gerota's, kidney, partial, renal, sutures, vicryl,

This scenario involves a surgical procedure for removing a renal mass suspected to be renal cell carcinoma. The stakes are high because the procedure addresses a potentially life-threatening condition (cancer) with significant risks and complications such as bleeding, infection, and potential kidney damage. However, the operation was completed without complications, which reduces the stakes post-procedure. The nature of the condition (cancer) and the surgical intervention's potential impact on the patient's health make it a high-stakes situation.


Medical Specialty: Gastroenterology
Sample Name: Esophagogastroduodenoscopy with Biopsies

PREOPERATIVE DIAGNOSES:,1.  Gastroesophageal reflux disease.,2.  Chronic dyspepsia.,POSTOPERATIVE DIAGNOSES:,1.  Gastroesophageal reflux disease.,2.  Chronic dyspepsia.,3.  Alkaline reflux gastritis.,4.  Gastroparesis.,5.  Probable Billroth II anastomosis.,6.  Status post Whipple's pancreaticoduodenectomy.,PROCEDURE PERFORMED:,  Esophagogastroduodenoscopy with biopsies.,INDICATIONS FOR PROCEDURE: , This is a 55-year-old African-American female who had undergone Whipple's procedure approximately five to six years ago for a benign pancreatic mass.  The patient has pancreatic insufficiency and is already on replacement.  She is currently using Nexium.  She has continued postprandial dyspepsia and reflux symptoms.  To evaluate this, the patient was boarded for EGD.  The patient gave informed consent for the procedure.,GROSS FINDINGS: , At the time of EGD, the patient was found to have alkaline reflux gastritis.  There was no evidence of distal esophagitis.  Gastroparesis was seen as there was retained fluid in the small intestine.  The patient had no evidence of anastomotic obstruction and appeared to have a Billroth II reconstruction by gastric jejunostomy.  Biopsies were taken and further recommendations will follow.,PROCEDURE:  ,The patient was taken to the Endoscopy Suite.  The heart and lungs examination were unremarkable.  The vital signs were monitored and found to be stable throughout the procedure.  The patient's oropharynx was anesthetized with Cetacaine spray.  She was placed in left lateral position.  The patient had the video Olympus GIF gastroscope model inserted per os and was advanced without difficulty through the hypopharynx.  GE junction was in normal position.  There was no evidence of any hiatal hernia.  There was no evidence of distal esophagitis.  The gastric remnant was entered.  It was noted to be inflamed with alkaline reflux gastritis.  The anastomosis was open and patent.  The small intestine was entered.  There was retained fluid material in the stomach and small intestine and _______ gastroparesis.  Biopsies were performed.  Insufflated air was removed with withdrawal of the scope.  The patient's diet will be adjusted to postgastrectomy-type diet.  Biopsies performed.  Diet will be reviewed.  The patient will have an upper GI series performed to rule out more distal type obstruction explaining the retained fluid versus gastroparesis.  Reglan will also be added.  Further recommendations will follow.
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DESCRIPTION: Esophagogastroduodenoscopy with biopsies.  Gastroesophageal reflux disease, chronic dyspepsia, alkaline reflux gastritis, gastroparesis, probable Billroth II anastomosis, and status post Whipple's pancreaticoduodenectomy.

gastroenterology, gastroesophageal reflux disease, chronic dyspepsia, alkaline reflux gastritis, gastroparesis, whipple's pancreaticoduodenectomy, billroth ii anastomosis, gastroesophageal reflux, alkaline reflux, reflux gastritis, gif, esophagogastroduodenoscopy, dyspepsia, gastritis, anastomosis, pancreaticoduodenectomy, biopsies, alkaline, reflux,

The situation involves a complex medical case where a patient, who has had significant previous surgeries (Whipple's procedure and probable Billroth II anastomosis), is undergoing an esophagogastroduodenoscopy (EGD) with biopsies to evaluate persistent symptoms. While the procedure itself is fairly common in gastroenterology, the high-stakes element arises from the patient's complicated medical history, including pancreatic insufficiency and gastroparesis. The findings from the EGD will influence the management plan, including potential additional diagnostic testing and treatment modifications (e.g., diet changes and introduction of Reglan). The stakes are moderate because while the procedure is routine, the potential implications for the patient's ongoing treatment plan and quality of life could be significant.


Medical Specialty: Dentistry
Sample Name: Full Mouth Dental Rehabilitation - 2

OPERATION PERFORMED:,  Full mouth dental rehabilitation in the operative room under general anesthesia.,PREOPERATIVE DIAGNOSIS: , Severe dental caries.,POSTOPERATIVE DIAGNOSES:,1.  Severe dental caries.,2.  Non-restorable teeth.,COMPLICATIONS:,  None.,ESTIMATED BLOOD LOSS: , Minimal.,DURATION OF SURGERY: , 43 minutes.,BRIEF HISTORY:  ,The patient was first seen by me on 04/26/2007.  She had a history of open heart surgery at 11 months' of age.  She presented with severe anterior caries with most likely dental extractions needed.  Due to her young age, I felt that she would be best served in the safety of the hospital operating room.  After consultation with the mother, she agreed to have her treated in the safety of the hospital operating room at Children's Hospital.,OPERATIVE PREPARATION:  ,This child was brought to Hospital Day Surgery and is accompanied by her mother.  There I met with them and discussed the needs of the child, types of restorations to be performed, the risks and benefits of the treatment as well as the options and alternatives of the treatment.  After all their questions and concerns were addressed, I gave the informed consent to proceed with the treatment.  The patient's history and physical examination was reviewed.  Once she was cleared by Anesthesia and the child was taken back to the operating room.,OPERATIVE PROCEDURE:  ,The patient was placed on the surgical table in the usual supine position with all extremities protected.  Anesthesia was induced by mask.  The patient was then intubated with a nasal endotracheal tube and the tube was stabilized.  The head was wrapped and the eyes were taped shut for protection.  An angiocatheter was placed in the left hand and an IV was started.  The head and neck were draped with sterile towels, and the body was covered with a lead apron and sterile sheath.  A moist continuous throat pack was placed beyond the tonsillar pillars.  Plastic lip and cheek retractors were then placed.  Preoperative clinical photographs were taken.  Two posterior bitewing radiographs and two anterior periapical films were taken in the operating room with digital radiography.  After the radiographs were taken, the lead shield was removed.  Prophylaxis was then performed using prophy cup and fluoridated prophy paste.  The teeth were then rinsed well and the patient's oral cavity was suctioned clean.  Clinical and radiographic examinations followed and areas of decay were noted.  During the restorative phase, these areas of decay were entered into and removed.  Entry was made to the level of the dental-enamel junction and beyond as necessary to remove it.  Final caries was removed and was confirmed upon reaching hard, firm sounding dentin.  Teeth restored with amalgam had a dentin tubular seal placed prior to amalgam placement.  Non-restorable primary teeth would be extracted.,Upon conclusion of the restorative phase, the oral cavity was aspirated and found to be free of blood, mucus, and other debris.  The original treatment plan was verified with the actual treatment provided.  Postoperative clinical photographs were then taken.  The continuous gauze throat pack was removed with continuous suction with visualization.  Topical fluoride was then placed on the teeth.,At the end of the procedure, the child was undraped, extubated, and awakened in the operating room and taken to the recovery room breathing spontaneously with stable vital signs.,FINDINGS:  ,This young patient presented with mild generalized marginal gingivitis secondary to light generalized plaque accumulation and fair oral hygiene.  All primary teeth were present.  Dental caries were present on the following teeth:  Tooth D, E, F, and G caries on all surfaces; teeth J, lingual caries.  The remainder of her teeth and soft tissues were within normal limits.  The following restorations and procedures were performed:  Tooth D, E, F, and G were extracted and four sutures were placed one at each extraction site and tooth J lingual amalgam.,CONCLUSION:  ,The mother was informed of the completion of the procedure.  She was given a synopsis of the treatment provided as well as written and verbal instructions for postoperative care.  They will contact to my office in the event of immediate postoperative complications.  After full recovery, she was discharged from the recovery room in the care of her mother.
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DESCRIPTION: Full mouth dental rehabilitation in the operative room under general anesthesia.

dentistry, full mouth dental rehabilitation, dental rehabilitation, full mouth, dental caries, non-restorable teeth, dental extractions, throat pack, oral cavity, restorative phase, primary teeth, dental, anesthesia, mouth, rehabilitation, prophylaxis, oral, amalgam, tooth,

This situation involves full mouth dental rehabilitation on a young patient under general anesthesia. Given the patient’s history of open heart surgery, there are elevated risks associated with anesthesia. Although the procedure went smoothly with no complications, any surgery under general anesthesia can be high-stakes, especially in young patients due to potential risks related to anesthesia and the patient's medical history. The procedure's successful outcome does not reduce the innate high-stakes nature of performing surgery under these conditions.


Medical Specialty: Consult - History and Phy.
Sample Name: Consult/ER Report - OB/GYN

The patient states that she has abnormal menstrual periods and cannot remember the first day of her last normal menstrual period.  She states that she had spotting for three months daily until approximately two weeks ago, when she believes that she passed a fetus.  She states that upon removal of a tampon, she saw a tadpole like structure and believed it to be a fetus.  However, she states she did not know that she was pregnant at this time.  She denies any abdominal pain or vaginal bleeding.  She states that the pregnancy is unplanned; however, she would desire to continue the pregnancy.,PAST MEDICAL HISTORY:  Diabetes mellitus which resolved after weight loss associated with gastric bypass surgery.,PAST SURGICAL HISTORY:,1.  Gastric bypass.,2.  Bilateral carpal tunnel release.,3.  Laparoscopic cholecystectomy.,4.  Hernia repair after gastric bypass surgery.,5.  Thoracotomy.,6.  Knee surgery.,MEDICATIONS:,1.  Lexapro 10 mg daily.,2.  Tramadol 50 mg tablets two by mouth four times a day.,3.  Ambien 10 mg tablets one by mouth at bedtime.,ALLERGIES:  AMOXICILLIN CAUSES THROAT SWELLING.  AVELOX CAUSES IV SITE SWELLING.,SOCIAL HISTORY:  The patient denies tobacco, ethanol, or drug use.  She is currently separated from her partner who is the father of her 21-month-old daughter.  She currently lives with her parents in Greenville.  However, she was visiting the estranged boyfriend in Wilkesboro, this week.,GYN HISTORY:  The patient denies history of abnormal Pap smears or STDs.,OBSTETRICAL HISTORY:  Gravida 1 was a term spontaneous vaginal delivery, complicated only by increased blood pressures at the time of delivery.  Gravida 2 is current.,REVIEW OF SYSTEMS:  The 14-point review of systems was negative with the exception as noted in the HPI.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Blood pressure 134/45, pulse 130, respirations 28.  Oxygen saturation 100%.,GENERAL:  Patient lying quietly on a stretcher.  No acute distress.,HEENT:  Normocephalic, atraumatic.  Slightly dry mucous membranes.,CARDIOVASCULAR EXAM:  Regular rate and rhythm with tachycardia.,CHEST:  Clear to auscultation bilaterally.,ABDOMEN:  Soft, nontender, nondistended with positive bowel sounds.  No rebound or guarding.,SKIN:  Normal turgor.  No jaundice.  No rashes noted.,EXTREMITIES:  No clubbing, cyanosis, or edema.,NEUROLOGIC:  Cranial nerves II through XII grossly intact.,PSYCHIATRIC:  Flat affect.  Normal verbal response.,ASSESSMENT AND PLAN:  A 34-year-old Caucasian female, gravida 2 para 1-0-0-1, at unknown gestation who presents after suicide attempt.,1.  Given the substances taken, medications are unlikely to affect the development of the fetus.  There have been no reported human anomalies associated with Ambien or tramadol use.  There is, however, a 4% risk of congenital anomalies in the general population.,2.  Recommend quantitative HCG and transvaginal ultrasound for pregnancy dating.,3.  Recommend prenatal vitamins.,4.  The patient to follow up as an outpatient for routine prenatal care.,
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DESCRIPTION: A female with unknown gestational age who presents to the ED after a suicide attempt.

This situation involves a potential pregnancy and a recent suicide attempt, both of which are critical medical and mental health issues requiring immediate and careful attention. The implications can be severe for both the patient's mental health and the potential risks to the fetus. Medical and psychological interventions are necessary to ensure the safety and well-being of both the patient and the unborn child. This makes it a high-stakes scenario, as it involves emergency healthcare intervention and potentially life-threatening consequences.


Medical Specialty: Endocrinology
Sample Name: Acute Cystitis & Diabetes Type II

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

The patient's situation involves uncontrolled Type II diabetes and acute cystitis, both of which are medical concerns that do require attention. While uncontrolled diabetes can lead to severe complications over time, and cystitis can cause discomfort and potentially lead to kidney infections, neither condition is currently life-threatening based on the provided information. The vital signs are stable, and there are no acute critical symptoms reported. The situation involves a need for medical intervention and monitoring, particularly the diabetic management, but it is not immediately dangerous or life-threatening at this point.


Medical Specialty: Urology
Sample Name: Bladder Biopsies & Fulguration

PREOPERATIVE DIAGNOSIS:,  Bladder lesions with history of previous transitional cell bladder carcinoma.,POSTOPERATIVE DIAGNOSIS: , Bladder lesions with history of previous transitional cell bladder carcinoma, pathology pending.,OPERATION PERFORMED:  ,Cystoscopy, bladder biopsies, and fulguration.,ANESTHESIA: , General.,INDICATION FOR OPERATION: , This is a 73-year-old gentleman who was recently noted to have some erythematous, somewhat raised bladder lesions in the bladder mucosa at cystoscopy.  He was treated for a large transitional cell carcinoma of the bladder with TURBT in 2002 and subsequently underwent chemotherapy because of pulmonary nodules.  He has had some low grade noninvasive small tumor recurrences on one or two occasions over the past 18 months.  Recent cystoscopy raises suspicion of another recurrence.,OPERATIVE FINDINGS: , The entire bladder was actually somewhat erythematous with mucosa looking somewhat hyperplastic particularly in the right dome and lateral wall of the bladder.  Scarring was noted along the base of the bladder from the patient's previous cysto TURBT.  Ureteral orifice on the right side was not able to be identified.  The left side was unremarkable.,DESCRIPTION OF OPERATION: , The patient was taken to the operating room.  He was placed on the operating table.  General anesthesia was administered after which the patient was placed in the dorsal lithotomy position.  The genitalia and lower abdomen were prepared with Betadine and draped subsequently.  The urethra and bladder were inspected under video urology equipment (25 French panendoscope) with the findings as noted above.  Cup biopsies were taken in two areas from the right lateral wall of the bladder, the posterior wall of bladder, and the bladder neck area.  Each of these biopsy sites were fulgurated with Bugbee electrodes.  Inspection of the sites after completing the procedure revealed no bleeding and bladder irrigant was clear.  The patient's bladder was then emptied.  Cystoscope removed and the patient was awakened and transferred to the postanesthetic recovery area.  There were no apparent complications, and the patient appeared to tolerate the procedure well.  Estimated blood loss was less than 15 mL.
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DESCRIPTION: Cystoscopy, bladder biopsies, and fulguration.  Bladder lesions with history of previous transitional cell bladder carcinoma, pathology pending.

urology, cystoscope, carcinoma, transitional cell bladder carcinoma, bladder lesions, bladder, fulguration, biopsies, cystoscopy,

The medical situation involves a patient with a history of bladder cancer undergoing a procedure for suspected recurring bladder lesions. The stakes are moderately high due to the need to confirm or rule out cancer recurrence, which can impact the patient's treatment plan and prognosis. The procedure itself (cystoscopy, biopsies, and fulguration) is routine and was completed without complications, but the potential for recurrence of transitional cell carcinoma makes the situation more significant.


Medical Specialty: Orthopedic
Sample Name: Anterior Cervical Discectomy & Fusion - 9

PREOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus C5-C6.,POSTOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus C5-C6.,PROCEDURE:,  Anterior cervical discectomy fusion C5-C6 followed by instrumentation C5-C6 with titanium dynamic plating system, Aesculap.  Operating microscope was used for both illumination and magnification.,FIRST ASSISTANT: , Nurse practitioner.,PROCEDURE IN DETAIL: , The patient was placed in supine position.  The neck was prepped and draped in the usual fashion for anterior discectomy and fusion.  An incision was made midline to the anterior body of the sternocleidomastoid at C5-C6 level.  The skin, subcutaneous tissue, and platysma muscle was divided exposing the carotid sheath, which was retracted laterally.  Trachea and esophagus were retracted medially.  After placing the self-retaining retractors with the longus colli muscles having been dissected away from the vertebral bodies at C5 and C6 and confirming our position with intraoperative x-rays, we then proceeded with the discectomy.,We then cleaned out the disc at C5-C6 after incising the annulus fibrosis.  We cleaned out the disc with a combination of angled and straight pituitary rongeurs and curettes, and the next step was to clean out the disc space totally.  With this having been done, we then turned our attention with the operating microscope to the osteophytes.  We drilled off the vertebral osteophytes at C5-C6, as well as the uncovertebral osteophytes.  This was removed along with the posterior longitudinal ligament.  After we had done this, the dural sac was opposed very nicely and both C6 nerve roots were thoroughly decompressed.  The next step after the decompression of the thecal sac and both C6 nerve roots was the fusion.  We observed that there was a ____________ in the posterior longitudinal ligament.  There was a free fragment disc, which had broken through the posterior longitudinal ligament just to the right of midline.,The next step was to obtain the bone from the back bone, using cortical cancellous graft 10 mm in size after we had estimated the size.  That was secured into place with distraction being applied on the vertebral bodies using vertebral body distractor.,After we had tapped in the bone plug, we then removed the distraction and the bone plug was fitting nicely.,We then use the Aesculap cervical titanium instrumentation with the 16-mm screws.  After securing the C5-C6 disc with four screws and titanium plate, x-rays showed good alignment of the spine, good placement of the bone graft, and after x-rays showed excellent position of the bone graft and instrumentation, we then placed in a Jackson-Pratt drain in the prevertebral space brought out through a separate incision.  The wound was closed with 2-0 Vicryl for subcutaneous tissues and skin was closed with Steri-Strips.  Blood loss during the operation was less than 10 mL.  No complications of the surgery.  Needle count, sponge count, and cottonoid count were correct.,
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DESCRIPTION: Herniated nucleus pulposus C5-C6.  Anterior cervical discectomy fusion C5-C6 followed by instrumentation C5-C6 with titanium dynamic plating system, Aesculap.  Operating microscope was used for both illumination and magnification.

orthopedic, aesculap, titanium dynamic plating system, anterior cervical discectomy, herniated nucleus pulposus, cervical discectomy, operating microscope, longitudinal ligament, discectomy, anterior, instrumentation, cervical, titanium

This surgical procedure summary indicates that the user is undertaking an Anterior Cervical Discectomy and Fusion. This is a specialized surgical procedure primarily intended to alleviate symptoms arising from a herniated disk by removing part of the offending disc and stabilizing the affected vertebrae with a fusion. The procedure involves several critical steps and complications can arise which could have significant impacts on patient outcomes and quality of life, such as potential nerve damage or the necessity for additional surgeries. Furthermore, the neck is a sensitive area and any surgery performed in this region carries substantial risks. Hence, it is considered high-stakes due to the potential impact on the patient's neurological functions and overall health.


Medical Specialty: Urology
Sample Name: Circumcision

PREOPERATIVE DIAGNOSIS:,  Phimosis.,POSTOPERATIVE DIAGNOSES:,  Phimosis.,OPERATIONS:,  Circumcision.,ANESTHESIA: , LMA.,EBL:,  Minimal.,FLUIDS: , Crystalloid.,BRIEF HISTORY: , This is a 3-year-old male, who was referred to us from Dr. X's office with phimosis.  The patient had spraying of urine and ballooning of the foreskin with voiding.  The urine seemed to have collected underneath the foreskin and then would slowly drip out.  Options such as dorsal slit, circumcision, watchful waiting by gently pulling the foreskin back were discussed.  Risk of anesthesia, bleeding, infection, pain, scarring, and expected complications were discussed.  The patient's family understood all the complications and wanted to proceed with the procedure.  Consent was obtained using interpreter.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the OR and anesthesia was applied.  The patient was placed in supine position.  The patient was prepped and draped in usual sterile fashion.  All the penile adhesions were released prior to the prepping.  The extra foreskin was marked off, 1 x 3 Gamco clamp was used.  Hemostasis was obtained after removing the extra foreskin using the Gamco clamp.,Using 5-0 Monocryl, 4 quadrant stitches were placed and horizontal mattress suturing was done.  There was excellent hemostasis.  Dermabond was applied.  The patient was brought to recovery at the end of the procedure in stable condition.
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DESCRIPTION: The patient had spraying of urine and ballooning of the foreskin with voiding.

urology, ballooning of the foreskin, spraying of urine, gamco clamp, spraying, ballooning, circumcision, urine, phimosis, foreskin

The situation involves a routine medical procedure, circumcision, performed on a 3-year-old male diagnosed with phimosis. The procedure was planned, and the risks were communicated to the family, who consented to it. While the procedure involves typical surgical risks such as anesthesia, bleeding, and infection, these are common considerations in surgeries and circumcision itself is a frequently performed procedure in urology. The stakes are moderate because it involves a young child under anesthesia, yet it doesn't involve life-threatening conditions or emergencies.


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

Medical Specialty: Neurosurgery
Sample Name: Anterior Cervical Discectomy & Fusion

PREOPERATIVE DIAGNOSES:,  Cervical spondylotic myelopathy with cord compression and cervical spondylosis.,POSTOPERATIVE DIAGNOSES:,  Cervical spondylotic myelopathy with cord compression and cervical spondylosis.  In addition to this, he had a large herniated disk at C3-C4 in the midline.,PROCEDURE: , Anterior cervical discectomy fusion C3-C4 and C4-C5 using operating microscope and the ABC titanium plates fixation with bone black bone procedure.,PROCEDURE IN DETAIL: , The patient placed in the supine position, the neck was prepped and draped in the usual fashion.  Incision was made in the midline the anterior border of the sternocleidomastoid at the level of C4.  Skin, subcutaneous tissue, and vertebral muscles divided longitudinally in the direction of the fibers and the trachea and esophagus was retracted medially.  The carotid sheath was retracted laterally after dissecting the longus colli muscle away from the vertebral osteophytes we could see very large osteophytes at C4-C5.  It appeared that the C5-C6 disk area had fused spontaneously.  We then confirmed that position by taking intraoperative x-rays and then proceeded to do discectomy and fusion at C3-C4, C4-C5.,After placing distraction screws and self-retaining retractors with the teeth beneath the bellies of the longus colli muscles, we then meticulously removed the disk at C3-C4, C4-C5 using the combination of angled strip, pituitary rongeurs, and curettes after we had incised the anulus fibrosus with #15 blade.,Next step was to totally decompress the spinal cord using the operating microscope and high-speed cutting followed by the diamond drill with constant irrigation.  We then drilled off the uncovertebral osteophytes and midline osteophytes as well as thinning out the posterior longitudinal ligaments.  This was then removed with 2-mm Kerrison rongeur.  After we removed the posterior longitudinal ligament, we could see the dura pulsating nicely.  We did foraminotomies at C3-C4 as well as C4-C5 as well.  After having totally decompressed both the cord as well as the nerve roots of C3-C4, C4-C5, we proceeded to the next step, which was a fusion.,We sized two 8-mm cortical cancellous grafts and after distracting the bone at C3-C4, C4-C5, we gently tapped the grafts into place.  The distraction was removed and the grafts were now within.  We went to the next step for the procedure, which was the instrumentation and stabilization of the fused area.,We then placed a titanium ABC plate from C3-C5, secured it with 16-mm titanium screws.  X-rays showed good position of the screws end plate.,The next step was to place Jackson-Pratt drain to the vertebral fascia.  Meticulous hemostasis was obtained.  The wound was closed in layers using 2-0 Vicryl for the subcutaneous tissue.  Steri-Strips were used for skin closure.  Blood loss less than about 200 mL.  No complications of the surgery.  Needle counts, sponge count, and cottonoid count was correct.
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DESCRIPTION: Anterior cervical discectomy fusion C3-C4 and C4-C5 using operating microscope and the ABC titanium plates fixation with bone black bone procedure.  Cervical spondylotic myelopathy with cord compression and cervical spondylosis.

neurosurgery, titanium plates fixation, bone black bone procedure, anterior cervical discectomy, titanium plates, cervical discectomy, spondylotic myelopathy, cord compression, cervical spondylosis, foraminotomies, cervical, anterior

The situation involves a detailed and complex neurosurgical procedure, Anterior Cervical Discectomy and Fusion (ACDF), addressing cervical spondylotic myelopathy and disc herniation. This is a high-stakes medical process as it involves decompression of the spinal cord and stabilization of the cervical spine, which if not performed correctly, can lead to significant neurological deficits or even be life-threatening. The precision required to avoid complications such as damage to nerve roots, excessive blood loss, or infection further elevates the stakes. Nevertheless, the description indicates that the procedure went smoothly with no complications.


Medical Specialty: Surgery
Sample Name: Removal of Venous Port

PREOPERATIVE DIAGNOSIS: , Acute lymphocytic leukemia in remission.,POSTOPERATIVE DIAGNOSIS: , Acute lymphocytic leukemia in remission.,OPERATION PERFORMED:  ,Removal of venous port.,ANESTHESIA: , General.,INDICATIONS: , This 9-year-old young lady presented with ALL in Orange County and had a port placed at that time.  She subsequently has now undergone chemotherapy here and is now off therapy.  She no longer needs her venous port so, comes to the operating room today for its removal.,OPERATIVE PROCEDURE: , After the induction of general anesthetic, the exit site was prepped and draped in usual manner.  The previous incision was opened by excising the old scar.  The port pocket was then opened and the port was removed from the pocket.  There was a resistance to the catheter being removed and so therefore, we began following the catheter along its path opening the tract until finally the catheter seemed to come free and could be pulled out without difficulty.  The port pocket was then closed using a #3-0 Vicryl in subcutaneous tissue, #5-0 subcuticular Monocryl in the skin.  Sterile dressing was applied.  Young lady was awakened and taken to the recovery room in satisfactory condition.
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DESCRIPTION: Acute lymphocytic leukemia in remission, removal of venous port.

surgery, removal of venous port, acute lymphocytic leukemia, venous port, lymphocytic, leukemia, venous

The procedure involves the removal of a venous port in a 9-year-old patient who is in remission from acute lymphocytic leukemia. The situation does not involve an active life-threatening condition since the leukemia is in remission. The removal of the venous port is a routine, planned surgical procedure and is medically necessary as the patient no longer needs the port due to completion of chemotherapy treatment. However, given that the patient is a child and general anesthesia is involved, there are inherent risks that elevate the stakes moderately, though the procedure itself is considered standard in surgical practice.


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

CHIEF COMPLAINT:,  GI bleed.,HISTORY OF PRESENT ILLNESS:,  The patient is an 80-year-old white female with history of atrial fibrillation, on Coumadin, who presented as outpatient, complaining of increasing fatigue.  CBC revealed microcytic anemia with hemoglobin of 8.9.  Stool dark brown, strongly OB positive.  The patient denied any shortness of breath.  No chest pain.  No GI complaints.  The patient was admitted to ABCD for further evaluation.,PAST MEDICAL HISTORY:  ,Significant for atrial fibrillation, hypertension, osteoarthritis of the knees, hypercholesterolemia, non-insulin-dependent diabetes mellitus, asthma, and hypothyroidism.,PHYSICAL EXAMINATION:,GENERAL:  The patient is in no acute distress.,VITAL SIGNS:  Stable.,HEENT:  Benign.,NECK:  Supple.  No adenopathy.,LUNGS:  Clear with good air movement.,HEART:  Irregularly regular.  No gallops.,ABDOMEN:  Positive bowel sounds, soft, and nontender.  No masses or organomegaly.,EXTREMITIES:  1+ lower extremity edema bilaterally.,HOSPITAL COURSE: , The patient underwent upper endoscopy performed by Dr. A, which revealed erosive gastritis.  Colonoscopy did reveal diverticulosis as well as polyp, which was resected.  The patient tolerated the procedure well.  She was transfused, and prior to discharge hemoglobin was stable at 10.7.  The patient was without further GI complaints.  Coumadin was held during hospital stay and recommendations were given by GI to hold Coumadin for an additional three days after discharge then resume.  The patient was discharged with outpatient PMD, GI, and Cardiology followup.,DISCHARGE DIAGNOSES:,1.  Upper gastrointestinal bleed.,2.  Anemia.,3.  Atrial fibrillation.,4.  Non-insulin-dependent diabetes mellitus.,5.  Hypertension.,6.  Hypothyroidism.,7.  Asthma.,CONDITION UPON DISCHARGE: , Stable.,MEDICATIONS: , Feosol 325 mg daily, multivitamins one daily, Protonix 40 mg b.i.d., KCl 20 mEq daily, Lasix 40 mg b.i.d., atenolol 50 mg daily, Synthroid 80 mcg daily, Actos 30 mg daily, Mevacor 40 mg daily, and lisinopril 20 mg daily.,ALLERGIES:,  None.,DIET: , 1800-calorie ADA.,ACTIVITY: , As tolerated.,FOLLOWUP: , The patient to hold Coumadin through weekend.  Followup CBC and INR were ordered.  Outpatient followup as arranged.
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DESCRIPTION: GI bleed.   Upper gastrointestinal bleed.  CBC revealed microcytic anemia.

The situation involves an elderly patient with a GI bleed and multiple comorbidities, including atrial fibrillation, which requires anticoagulation therapy. Managing anticoagulation in the presence of a GI bleed is complex and carries potential for serious complications such as stroke or rebleeding if not handled properly. The patient was stabilized and discharged with clear follow-up and medication management plans, indicating that the immediate high-stakes situation is mitigated but still demands careful monitoring and adherence to follow-up care.


Medical Specialty: Orthopedic
Sample Name: Arthrotomy & I&D

PREOPERATIVE DIAGNOSIS: , Hemarthrosis, left knee, status post total knee replacement, rule out infection.,POSTOPERATIVE DIAGNOSIS: , Hemarthrosis, left knee, status post total knee replacement, rule out infection.,OPERATIONS:,1.  Arthrotomy, left total knee.,2.  Irrigation and debridement, left knee.,3.  Polyethylene exchange, left knee.,COMPLICATION: , None.,TOURNIQUET TIME:  ,58 minutes.,ESTIMATED BLOOD LOSS: , Minimal.,ANESTHESIA:  ,General.,INDICATIONS:  ,This patient underwent an uncomplicated left total knee replacement.  Postoperatively, unfortunately did not follow up with PT/INR blood test and he was taking Coumadin.  His INR was seemed to elevated and developed hemarthrosis.  Initially, it did look very benign, although over the last 24 hours it did become irritable and inflamed, and he therefore was indicated with the above-noted procedure.,This procedure as well as alternatives was discussed in length with the patient and he understood them well.  Risks and benefits were also discussed.  Risks such as bleeding, infection, damage to blood vessels, damage to nerve roots, need for further surgeries, chronic pain with range of motion, risk of continued discomfort, risk of need for further reconstructive procedures, risk of need for total knee revision, risk of blood clots, pulmonary embolism, myocardial infarction, and risk of death were discussed.  He understood them well.  All questions were answered and he signed consent for the procedure as described.,DESCRIPTION OF PROCEDURE: , The patient was placed on operating table and general anesthesia was achieved.  The left lower extremity was then prepped and draped in the usual sterile manner.  The leg was elevated and the tourniquet was inflated to 325 mmHg.  A longitudinal incision was then made and carried down through subcutaneous tissues.  This was made through the prior incision site.  There were some fatty necrotic tissues through the incision region and all necrotic tissue was debrided sharply on both sides of the incision site.  Medial and lateral flaps were then made.  The prior suture was identified, the suture removed and then a medial parapatellar arthrotomy was then performed.  Effusion within the knee was noted.  All hematoma was evacuated.  I then did flex the knee and removed the polyethylene.  Once the polyethylene was removed I did irrigate the knee with total of 9 liters of antibiotic solution.  Further debridement was performed of all inflamed tissue and thickened synovial tissue.  A 6 x 16-mm Stryker polyethylene was then snapped back in position.  The knee has excellent stability in all planes and I did perform a light manipulation to improve the flexion of the knee.  Further irrigation was performed on the all soft tissue in the knee with additional 3 liters of normal saline.  The knee was placed in a flexed position and the extensor mechanism was reapproximated using #2 Ethibond suture in a figure-of-eight manner.  The subcutaneous tissue was reapproximated in layers using #1 and 2-0 Vicryl sutures, and the skin was reapproximated using staples.  Prior to closure a Hemovac drain was inserted through a superolateral approach into the knee joint.,No complications were encountered throughout the procedure, and the patient tolerated the procedure well.  The patient was taken to recovery room in stable condition.
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DESCRIPTION: Hemarthrosis, left knee, status post total knee replacement, rule out infection.  Arthrotomy, irrigation and debridement, and polyethylene exchange, left knee.  No complications were encountered throughout the procedure.

The procedure described is a follow-up surgery after a total knee replacement due to complications involving hemarthrosis, with the possibility of infection. Although successfully performed without complications, the stakes are high due to the potential severity of post-surgical risks discussed, including infection, further surgeries, or even life-threatening conditions like pulmonary embolism. Additionally, it involves general anesthesia and significant physical intervention on a replaced knee joint, which inherently carry high stakes.


Medical Specialty: Surgery
Sample Name: Facial Laceration Closure

PREOPERATIVE DIAGNOSIS:,  Left supraorbital deep complex facial laceration measuring 6x2 cm.,POSTOPERATIVE DIAGNOSIS: , Left supraorbital deep complex facial laceration measuring 6x2 cm.,PROCEDURE PERFORMED: , Plastic closure of deep complex facial laceration measuring 6x2 cm.,ANESTHESIA: , Local anesthesia with 1% lidocaine with 1:100,000 epinephrine, total of 2 cc were used.,SPECIMENS: , None.,FINDINGS: , Deep complex left forehead laceration.,HISTORY: , The patient is a 23-year-old male who was intoxicated and hit with an unknown object to his forehead.  The patient subjectively had loss of consciousness on the scene and minimal bleeding from the left supraorbital laceration site.  He was brought to the Emergency Room, where a CAT scan of the head and facial bumps was performed, which were negative.,Prior to performing surgery informed consent was obtained from the patient who was well aware of the risks, benefits, alternatives and complications of the surgery to include infection, bleeding, cosmetic deformity, significant scarring, need for possible scar revision.  The patient was allowed to ask all questions he wanted, and they were answered in a language he could understand.  He wished to pursue surgery and signed the informed consent.,PROCEDURE: , The patient was placed in the supine position.  The wound was copiously irrigated with normal saline on irrigating tip.  After one liter of irrigation, the wound was prepped and draped in the usual sterile fashion.  The incision was then localized with a solution of 1% lidocaine with 1:100,000 epinephrine, a total of less than 2 cc was used.  We then reapproximated the wound in double-layered fashion with deep sutures of #5-0 Vicryl, two interrupted sutures were used, and then the skin was closed with interrupted sutures of #5-0 nylon.  The wound came together very nicely.  Tincture of Benzoin was placed.  Steri-Strips were placed over the top and a small amount of bacitracin was placed over the Steri-Strips.  The patient tolerated the procedure well with no complications.
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DESCRIPTION: Left supraorbital deep complex facial laceration measuring 6x2 cm.  Plastic closure of deep complex facial laceration measuring 6x2 cm.  The patient is a 23-year-old male who was intoxicated and hit with an unknown object to his forehead.  The patient subjectively had loss of consciousness on the scene and minimal bleeding from the left supraorbital laceration site.

surgery, plastic closure, facial laceration, deep complex facial laceration, steri strips, closure, bleeding, sterile, sutures, forehead, wound, supraorbital, facial, laceration

The situation involves a surgical procedure to close a facial laceration in a young male patient. While surgery always carries certain risks, such as infection or anesthesia complications, this particular surgery seems to be on the less severe end of the spectrum because it's a minor procedure using local anesthesia, and the patient had minimal bleeding with a negative CT scan for more serious injuries. The stakes are moderately elevated due to the location on the face, which involves considerations of cosmetic outcomes, but the procedure appears straightforward and routine without immediate life-threatening implications. Therefore, while it's important to perform carefully, the stakes aren't excessively high.


Medical Specialty: Urology
Sample Name: Inguinal Herniorrhaphy - 1

PREOPERATIVE DIAGNOSIS: , Inguinal hernia.,POSTOPERATIVE DIAGNOSIS: , Direct inguinal hernia.,PROCEDURE PERFORMED:,  Rutkow direct inguinal herniorrhaphy.,ANESTHESIA: , General endotracheal.,DESCRIPTION OF PROCEDURE:  ,After informed consent was obtained, the patient was brought to the operative suite and placed supine on the operating table.  General endotracheal anesthesia was induced without incident.  Preoperative antibiotics were given for prophylaxis against surgical infection.  The patient was prepped and draped in the usual sterile fashion.,A standard inguinal incision was made, and dissection was carried down to the external oblique aponeurosis using a combination of Metzenbaum scissors and Bovie electrocautery.  The external oblique aponeurosis was cleared of overlying adherent tissue, and the external ring was delineated.  The external oblique was then incised with a scalpel and this incision was carried out to the external ring using Metzenbaum scissors.  Having exposed the inguinal canal, the cord structures were separated from the canal using blunt dissection, and a Penrose drain was placed around the cord structures at the level of the pubic tubercle.  This Penrose drain was then used to retract the cord structures as needed.  Adherent cremasteric muscle was dissected free from the cord using Bovie electrocautery.,The cord was then explored using a combination of sharp and blunt dissection, and no sac was found.  The hernia was found coming from the floor of the inguinal canal medial to the inferior epigastric vessels.  This was dissected back to the hernia opening.  The hernia was inverted back into the abdominal cavity and a large PerFix plug inserted into the ring.  The plug was secured to the ring by interrupted 2-0 Prolene sutures.,The PerFix onlay patch was then placed on the floor of the inguinal canal and secured in place using interrupted 2-0 Prolene sutures.  By reinforcing the floor with the onlay patch, a new internal ring was thus formed.,The Penrose drain was removed.  The wound was then irrigated using sterile saline, and hemostasis was obtained using Bovie electrocautery.  The incision in the external oblique was approximated using a 2-0 Vicryl in a running fashion, thus reforming the external ring.  The skin incision was approximated with 4-0 Monocryl in a subcuticular fashion.  The skin was prepped with benzoin, and Steri-Strips were applied.  All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently taken to the recovery room in good and stable condition.
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DESCRIPTION: Direct inguinal hernia.  Rutkow direct inguinal herniorrhaphy.  A standard inguinal incision was made, and dissection was carried down to the external oblique aponeurosis using a combination of Metzenbaum scissors and Bovie electrocautery.

urology, cremasteric muscle, pubic tubercle, external oblique aponeurosis, inguinal herniorrhaphy, inguinal hernia, cord structures, penrose drain, bovie electrocautery, inguinal, herniorrhaphy, metzenbaum, bovie, electrocautery, cord, hernia

The described situation is a routine surgical procedure for repairing an inguinal hernia. While surgery always carries some risks and importance due to the need for anesthesia and sterile protocol, this type of procedure is generally considered low to moderate risk in the field of surgery. The description indicates the operation progressed without incident and the patient was stable afterward. Such surgeries are common and typically do not have high-stakes implications unless complications arise, which are not mentioned here.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Urinary Frequency & Urgency - Followup

HISTORY OF PRESENT ILLNESS:  ,This is a 55-year-old female with a history of stroke, who presents today for followup of frequency and urgency with urge incontinence.  This has been progressively worsening, and previously on VESIcare with no improvement.  She continues to take Enablex 50 mg and has not noted any improvement of her symptoms.  The nursing home did not do a voiding diary.  She is accompanied by her power of attorney.  No dysuria, gross hematuria, fever or chills.  No bowel issues and does use several Depends a day.,Recent urodynamics in April 2008, here in the office, revealed significant detrusor instability with involuntary urinary incontinence and low bladder volumes, and cystoscopy was unremarkable.,IMPRESSION:  ,Persistent frequency and urgency, in a patient with a history of neurogenic bladder and history of stroke.  This has not improved on VESIcare as well as Enablex.  Options are discussed.,We discussed other options of pelvic floor rehabilitation, InterStim by Dr. X, as well as more invasive procedure.  The patient and the power of attorney would like him to proceed with meeting Dr. X to discuss InterStim, which was briefly reviewed here today and brochure for this is provided today.  Prior to discussion, the nursing home will do an extensive voiding diary for one week, while she is on Enablex, and if this reveals no improvement, the patient will be started on Ventura twice daily and prescription is provided.  They will see Dr. X with a prior voiding diary, which is again discussed.  All questions answered.,PLAN:,  As above, the patient will be scheduled to meet with Dr. X to discuss option of InterStim, and will be accompanied by her power of attorney.  In the meantime, Sanctura prescription is provided, and voiding diaries are provided.  All questions answered.
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DESCRIPTION: Persistent frequency and urgency, in a patient with a history of neurogenic bladder and history of stroke.

soap / chart / progress notes, neurogenic bladder, urge incontinence, urgency, frequency, vesicare, enablex, persistent frequency and urgency, frequency and urgency, persistent frequency, voiding diary, voiding

The situation described involves a 55-year-old female with a history of stroke and neurogenic bladder, leading to worsening urinary frequency and urgency, which is impacting her quality of life. While this is a significant chronic medical issue, the stakes aren't extremely high since it doesn't immediately endanger her life. It is important to manage effectively to improve her quality of life and prevent potential complications like infections or further deterioration in her bladder function. Furthermore, the involvement of her power of attorney and the discussion of appropriate treatment options indicate that her care is being managed proactively. In a medical context, urgency and frequency without immediate life-threatening complications do not rank at the highest emergency level, but still require attention and an effective management plan.


Medical Specialty: Office Notes
Sample Name: Nephrology Office Visit - 2

HISTORY OF PRESENT ILLNESS:,  This is a 79-year-old white male who presents for a nephrology followup for his chronic kidney disease secondary to nephrosclerosis and nonfunctioning right kidney.  His most recent BUN and creatinine on 04/04/06 are 40/2.0, which is stable.  He denies any chest pain or tightness in his chest.  He denies any shortness of breath, nausea, or vomiting.  He denies any change to his appetite.  He denies any fevers, chills, dysuria, or hematuria.  He does report his blood pressure being checked at the senior center and reporting that it is improved.  The patient has stage III chronic kidney disease. ,PAST MEDICAL HISTORY:,
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DESCRIPTION: Nephrology office visit for followup of CKD.

The stakes in this situation are relatively moderate because the patient's chronic kidney disease (CKD) is being monitored through routine follow-up without any immediate life-threatening complications reported. The patient's vital markers like BUN and creatinine levels are stable, and there are no reports of severe symptoms such as chest pain or shortness of breath. The situation requires careful management but does not indicate a critical or emergency condition.