Medical Specialty: ENT - Otolaryngology
Sample Name: Microlaryngoscopy

PREOPERATIVE DIAGNOSIS:,  Airway obstruction secondary to laryngeal subglottic stenosis.,POSTOPERATIVE DIAGNOSIS:  ,Airway obstruction secondary to laryngeal subglottic stenosis and tracheal stenosis.,OPERATION PERFORMED: , Suspension microlaryngoscopy, rigid bronchoscopy, dilation of tracheal stenosis.,INDICATIONS FOR SURGERY:  ,The patient is a 56-year-old white female with a history of relapsing polychondritis, which resulted in saddle nose deformity in glottic and subglottic stenosis for which she has undergone number of procedures in the past to the upper airway.  She currently is trach dependent for her airway because of glottic and subglottic stenosis, but she is having no significant problems breathing and talking around her trach tube and came for further evaluation.  Endoscopic reevaluation of her tube and nature of the proposed procedure done.  Risk and complications of bleeding, infection, alteration of with speech or swallowing, failure to improve her airway, and loss of voice.  Cardiorespiratory anesthetic results were discussed in length.  The patient states she understood and wished to proceed.,DESCRIPTION OF OPERATION:,  The patient was taken to the operating room and placed in the supine position.  Under adequate general endotracheal anesthesia, the patient's #5 metal tracheostomy tube was removed and a #5 laser-safe endotracheal tube was inserted.  The patient was then prepared for endoscopy.  The Kantor laryngoscope was then inserted.  Oral cavity, hypopharynx, larynx, and nasal cavity showed good dentition with good tongue, buccal cavity, and mucosa without lesions.  Larynx was then ***** short epiglottis.  Larynx was suspended with significant scarring beginning in the supraglottic area with loss of laryngeal contour beginning in the supraglottis with extensive scar tissue at the level of the false cord obliteration of ventricles and true cords.  This appeared to be stable, and airway was patent at the supraglottic and glottic level with some narrowing at the subglottic level with mild-to-moderate subglottic stenosis, otherwise this appeared to be stable.  However, distally, the level of the trach site examined with the microscope and 0 and 30-degree telescopes.  The patient noted to have marked narrowing with dense scarring posterolaterally on the left securing good visualization of the trach tube.  The laryngoscope was removed, and a 5 x 30 pediatric rigid bronchoscope was then passed.  The LP contact tip laser was utilized to vaporize the scar tissue and release the scar banding following which the scope was passed and further dilation carried out.  Mid and distal trachea were widely patent.  Trachea and mainstem bronchi were patent without obvious disease.  The patient did not appear to have any relapsing polychondritis with progressive scar tissue at the level of the trach site and the posterior trachea wall was significant.  This was further dilated and following which was removed and a new #5 metal tracheostomy tube inserted.  The patient tolerated the procedure well without complications and was taken to recovery room in satisfactory condition.
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DESCRIPTION: Suspension microlaryngoscopy, rigid bronchoscopy, dilation of tracheal stenosis.

ent - otolaryngology, airway obstruction, oral cavity, bronchoscopy, buccal cavity, hypopharynx, laryngeal, larynx, microlaryngoscopy, nasal cavity, polychondritis, subglottic, tracheal stenosis, tracheostomy tube, scar tissue, subglottic stenosis, tracheal, airway, cavity, tube, scarring, stenosis,

This situation involves a medical procedure addressing airway obstruction due to laryngeal and tracheal stenosis, which can be life-threatening if not treated appropriately. The patient, who has a complex medical history and is tracheostomy dependent, undergoes a detailed surgical intervention to ensure her airway remains open. The stakes are high because any complication during the procedure could lead to significant respiratory distress or other adverse outcomes. However, the patient currently exhibits stability around her tracheostomy tube, and the procedure proceeded without complications, slightly reducing the overall risk.


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Medical Specialty: ENT - Otolaryngology
Sample Name: Mastoiditis - Discharge Summary

DISCHARGE DIAGNOSES:  ,1.  Suspected mastoiditis ruled out.,2.  Right acute otitis media.,3.  Severe ear pain resolving.,HISTORY OF PRESENT ILLNESS: , The patient is an 11-year-old male who was admitted from the ER after a CT scan suggested that the child had mastoiditis.  The child has had very severe ear pain and blood draining from the right ear.  The child had a temperature maximum of 101.4 in the ER.  The patient was admitted and started on IV Unasyn, which he tolerated well and required Morphine and Vicodin for pain control.  In the first 12 hours after admission, the patient's pain decreased and also swelling of his cervical area decreased.  The patient was evaluated by Dr. X from the ENT while in house.  After reviewing the CT scan, it was felt that the CT scan was not consistent with mastoiditis.  The child was continued on IV fluid and narcotics for pain as well as Unasyn until the time of discharge.  At the time of discharge his pain is markedly decreased about 2/10 and swelling in the area has improved.  The patient is also able to take p.o. well.,DISCHARGE PHYSICAL EXAMINATION:,GENERAL:  The patient is alert, in no respiratory distress.,VITAL SIGNS:  His temperature is 97.6, heart rate 83, blood pressure 105/57, respiratory rate 16 on room air.,HEENT:  Right ear shows no redness.  The area behind his ear is nontender.  There is a large posterior chains node that is nontender and the swelling in this area has decreased markedly.,NECK:  Supple.,CHEST:  Clear breath sounds.,CARDIAC:  Normal S1, S2 without murmur.,ABDOMEN:  Soft.  There is no hepatosplenomegaly or tenderness.,SKIN:  Warm and well perfused.,DISCHARGE WEIGHT: , 38.7 kg.,DISCHARGE CONDITION: , Good.,DISCHARGE DIET:,  Regular as tolerated.,DISCHARGE MEDICATIONS:  ,1.  Ciprodex Otic Solution in the right ear twice daily.,2.  Augmentin 500 mg three times daily x10 days.,FOLLOW UP:  ,1.  Dr. Y in one week (ENT).,2.  The primary care physician in 2 to 3 days.,TIME SPENT: , Approximate discharge time is 28 minutes.
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DESCRIPTION: Suspected mastoiditis ruled out, right acute otitis media, and severe ear pain resolving.  The patient is an 11-year-old male who was admitted from the ER after a CT scan suggested that the child had mastoiditis.

The situation involves a pediatric patient with a suspected case of mastoiditis, which was ruled out after admission and further evaluation. Although mastoiditis can be a serious condition requiring prompt treatment, in this case, it was not present. The patient's actual condition, acute otitis media, is common and generally treatable, and the patient responded well to treatment. Given the resolution of severe symptoms and the plan for continued outpatient care, this situation appears to be managed well, with a low risk of severe complications at discharge. Hence, the overall stakes from a medical urgency and risk perspective are moderate but not high.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: ENT - Otolaryngology
Sample Name: Myringotomy/Tube Insertion

PREOPERATIVE DIAGNOSES:,  Chronic otitis media with effusion, conductive hearing loss, and recurrent acute otitis media.,POSTOPERATIVE DIAGNOSES:,  Chronic otitis media with effusion, conductive hearing loss, and recurrent acute otitis media.,OPERATION: , Bilateral myringotomies, insertion of PE tubes, and pharyngeal anesthesia.,ANESTHESIA:  ,General via facemask.,ESTIMATED BLOOD LOSS: , None.,COMPLICATIONS: , None.,INDICATIONS:  ,The patient is a one-year-old with history of chronic and recurrent episodes of otitis media with persistent middle ear effusions resistant to medical therapy.,PROCEDURE: , The patient was brought to the operating room, was placed in supine position.  General anesthesia was begun via face mask technique.  Once an adequate level of anesthesia was obtained, the operating microscope was brought, positioned and visualized the right ear canal.  A small amount of wax was removed with a loop.  A 4-mm operating speculum was then introduced.  An anteroinferior quadrant radial myringotomy was then performed.  A large amount of mucoid middle ear effusion was aspirated from the middle ear cleft.  Reuter bobbin PE tube was then inserted, followed by Floxin otic drops and a cotton ball in the external meatus.  Head was then turned to the opposite side, where similar procedure was performed.  Once again, the middle ear cleft had a mucoid effusion.  A tube was inserted to an anteroinferior quadrant radial myringotomy.,Anesthesia was then reversed and the patient was transported to the recovery room having tolerated the procedure well with stable signs.
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DESCRIPTION: Bilateral myringotomies, insertion of PE tubes, and pharyngeal anesthesia.

ent - otolaryngology, bilateral myringotomies, insertion of pe tubes, chronic otitis media, conductive hearing loss, recurrent acute otitis media, reuter bobbin, radial myringotomy, ear cleft, pe tubes, middle ear, otitis media, effusion, otitis, media, ear, anesthesia

The procedure described is a myringotomy with the insertion of PE (pressure equalization) tubes, commonly performed on children with chronic and recurrent otitis media. Although surgery always comes with some level of risk, this is a relatively routine and low-risk procedure in pediatric ENT. The potential complications are generally minimal, and the document states there were no complications, estimated blood loss was none, and the patient tolerated the procedure well. While it involves general anesthesia, which always adds some risk and consideration, the stakes compared to many other surgeries are relatively low. Therefore, it's not a high-stakes situation in the context of surgical procedures.


Medical Specialty: ENT - Otolaryngology
Sample Name: Ethmoidectomy & Nasal Polypectomy

PROCEDURES PERFORMED:,1.  Functional endoscopic sinus surgery.,2.  Bilateral maxillary antrostomy.,3.  Bilateral total ethmoidectomy.,4.  Bilateral nasal polypectomy.,5.  Right middle turbinate reduction.,ANESTHESIA:,  General endotracheal tube.,BLOOD LOSS:,  Approximately 50 cc.,INDICATION: , This is a 48-year-old female with a history of chronic sinusitis as well as nasal polyposis that have been refractory to outpatient medical management.  She has underwent sinus surgery in the past approximately 12 years ago with the CT evaluation revealed evidence of chronic mucosal thickening within the maxillary and ethmoid sinuses as well as the presence of polyposis within the nasal cavities bilaterally.,PROCEDURE:  ,After all risks, benefits, and alternatives have been discussed with the patient in detail, informed consent was obtained.  The patient was brought to the operative suite where she was placed in supine position and general anesthesia was delivered by the Department of Anesthesia.  The patient was rotated 90 degrees away where cotton pledgets saturated with 4 cc of 10% cocaine solution were inserted into the nasal cavity.  The nasal septum, as well as the turbinates were then localized with a mixture of 1% lidocaine with 1:100,000 epinephrine solution.  The patient was then prepped and draped in the usual fashion.,Attention was directed first to the left nasal cavity.  A zero-degree sinus endoscope was inserted into the nasal cavity down to the level of the nasopharynx.  The initial examination revealed a gross polypoid disease emanating from the sphenoid sinuses as well as off the supreme turbinate.  There was also polypoid disease present within the left middle meatus.  Nasopharynx was visualized with a patent eustachian tube.  At this point, the XPS micro debrider was used to take down all the polyps emanating from the inferior surface of the left middle turbinate as well as from the supreme turbinate.  The ostium to the sphenoid sinus was visualized and was not entered.  At this point, the left middle turbinate was localized and then medialized with the use of a freer elevator.  A ball-tip probe was then used to localize the openings for the natural maxillary ostium.  Side-biting forceps were used to take down the uncinate process and was further taken down with the use of the microdebrider.  The opening of the maxillary sinus was visualized.  The posterior fontanelle was taken down with the use of straight line forceps.  It should be mentioned that tissue was very thick and polypoid with chronic inflammatory changes evident.  The maxillary sinus ostia was then suctioned with Olive-tip suction and maxillary wash was performed.  The remainder of the anterior ethmoid was then cleaned again removing excess polypoid tissue.  The basal lamella was visualized and the posterior ethmoid air cells were then entered with use of the microdebrider as the surgical assistant palpated the patient's eyes for any vibration.  All polypoid tissue was collected in the microdebrider and sent as a surgical specimen.  Once all polypoid tissue has been removed, the cocaine pledgets were reinserted into the ethmoid air cells for hemostatic purposes.  Attention was then directed to the right nasal cavity.  Again, a sinus endoscope was inserted.  Inspection revealed a grossly hypertrophied turbinate.  It was felt that this enlarged and polypoid turbinate was contributing the patient's symptoms.  Therefore, the turbinate was localized and a hemostat was used to crush the mid portion of the turbinate, which was then resected with use of side-biting scissors as well the Takahashi forceps.  Sinus endoscope was then inserted all the way down through the nasopharynx.  Again, the eustachian tube was visualized without any obstructing lesions or masses.  Upon retraction, there was again polypoid tissue noted within the ethmoid sinuses.  The ball-tip probe was again used to locate the right maxillary ostium.  The side-biting forceps was used further take down the uncinate process.  The maxillary ostium was then widened with use of a XPS microdebrider.  A maxillary sinus wash was then performed.  Now, the attention was directed to the ethmoid air cells.  It should be mentioned again that the tissue of the anterior ethmoid was very thickened and polypoid.  This was again taken down with the use of XPS microdebrider while the surgical assistant carefully palpated the patient's eye.,Once all polypoid tissue have been removed, some bleeding that was encountered was controlled with the use of suction cautery in a very conservative manner.  Once all bleeding has been controlled, all surgical instruments were removed and Merocel packing was placed in the bilateral nasal cavities with the intent to remove in the recovery room.  At this point, the procedure was felt to be complete.  The patient was awakened and taken to the recovery room without incident.
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DESCRIPTION: Functional endoscopic sinus surgery, bilateral maxillary antrostomy, bilateral total ethmoidectomy, bilateral nasal polypectomy, and right middle turbinate reduction.

ent - otolaryngology, endoscopic sinus surgery, maxillary antrostomy, ethmoidectomy, nasal polypectomy, turbinate reduction, sinus surgery, sinus endoscope, maxillary sinus, nasal cavity, polypoid tissue, sinus, maxillary, turbinate, polypoid, nasal, total, ostium, microdebrider,

This scenario describes a complex surgical procedure involving functional endoscopic sinus surgery that addresses chronic sinusitis and nasal polyposis. The patient's condition is refractory to non-surgical treatments, necessitating this intervention. The stakes are relatively high due to the complexity of the procedure, the use of general anesthesia, and the potential risks and complications associated with surgery near sensitive structures like the sinuses and the eye orbit. However, it is a routine procedure for an ENT specialist and not an emergency, lowering the stakes slightly. The potential for complications like excessive bleeding, infection, or damage to adjacent structures adds to the critical nature of the procedure, but these are well-managed in a controlled surgical environment.


Medical Specialty: ENT - Otolaryngology
Sample Name: Fat Harvesting

PREOPERATIVE DIAGNOSIS: , Incompetent glottis.,POSTOPERATIVE DIAGNOSIS:,  Incompetent glottis.,OPERATION PERFORMED:,1.  Fat harvesting from the upper thigh.,2.  Micro-laryngoscopy.,3.  Fat injection thyroplasty.,FINDINGS AND PROCEDURE: , With the patient in the supine position under adequate general endotracheal anesthesia, the operative area was prepped and draped in a routine fashion.  A 1-cm incision was made in the upper thigh, and approximately 5 cc of fat was liposuctioned from the subcutaneous space.  After this had been accomplished, the wound was closed with an interrupted subcuticular suture of 4-0 chromic and a light compression dressing was applied.,Next, the fat was placed in a urine strainer and copiously washed using 100 cc of PhysioSol containing 100 units of regular insulin.  After this had been accomplished, it was placed in a 3-cc BD syringe and, thence, into the Stasney fat injector device.  Next, a Dedo laryngoscope was used to visualize the larynx, and approximately *** cc of fat was injected into the right TA muscle and *** cc of fat into the left TA muscle.,The patient tolerated the procedure well and was returned to the recovery room in satisfactory condition.  Estimated blood loss was negligible.
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DESCRIPTION: Incompetent glottis.  Fat harvesting from the upper thigh, micro-laryngoscopy, fat injection thyroplasty.

ent - otolaryngology, dedo laryngoscope, physiosol, micro laryngoscopy, fat injection, fat harvesting, incompetent glottis, laryngoscopy, thyroplasty, glottis, thigh

The procedure described involves addressing an incompetent glottis, which can affect a patient's ability to speak and potentially breathe properly. Fat harvesing and injection are involved in surgical corrections requiring precision. While on the spectrum of medical procedures, this is relatively routine for ENT specialists, it still carries moderate stakes due to the implications on vocal function and the need for anesthesia. However, the procedure appears to have been successfully completed with negligible blood loss and no complications noted during surgery.


Medical Specialty: ENT - Otolaryngology
Sample Name: ENT Consult

HISTORY:,  The patient is a 51-year-old female that was seen in consultation at the request of Dr. X on 06/04/2008 regarding chronic nasal congestion, difficulty with swallowing, and hearing loss.  The patient reports that she has been having history of recurrent sinus infection, averages about three times per year.  During the time that she gets the sinus infections, she has nasal congestion, nasal drainage, and also generally develops an ear infection as well.  The patient does note that she has been having hearing loss.  This is particular prominent in the right ear now for the past three to four years.  She does note popping after blowing the nose.  Occasionally, the hearing will improve and then it plugs back up again.  She seems to be plugged within the nasal passage, more on the right side than the left and this seems to be year round issue with her.  She tried Flonase nasal spray to see if this help with this and has been taking it, but has not seen a dramatic improvement.  She has had a history of swallowing issues and that again secondary to the persistent postnasal drainage.  She feels that she is having a hard time swallowing at times as well.  She has complained of a lump sensation in the throat that tends to come and go.  She denies any cough, no hemoptysis, no weight change.  No night sweats, fever or chills has been noted.  She is having at this time no complaints of tinnitus or vertigo.  The patient presents today for further workup, evaluation, and treatment of the above-listed symptoms.,REVIEW OF SYSTEMS:  ,ALLERGY/IMMUNOLOGIC:  History of seasonal allergies.  She also has severe allergy to penicillin and bee stings.,CARDIOVASCULAR:  Pertinent for hypercholesterolemia.,PULMONARY:  She has a history of cough, wheezing.,GASTROINTESTINAL:  Negative.,GENITOURINARY:  Negative.,NEUROLOGIC:  She has had a history of TIAs in the past.,VISUAL:  She does have history of vision change, wears glasses.,DERMATOLOGIC:  Negative.,ENDOCRINE:  Negative.,MUSCULOSKELETAL:  History of joint pain and bursitis.,CONSTITUTIONAL:  She has a history of chronic fatigue.,ENT:  She has had a history of cholesteatoma removal from the right middle ear and previous tympanoplasty with a progressive hearing loss in the right ear over the past few years according to the patient.,PSYCHOLOGIC:  History of anxiety, depression.,HEMATOLOGIC:  Easy bruising.,PAST SURGICAL HISTORY: , She has had right tympanoplasty in 1984.  She has had a left carotid endarterectomy, cholecystectomy, two C sections, hysterectomy, and appendectomy.,FAMILY HISTORY: , Mother, history of vaginal cancer and hypertension.  Brother, colon CA.  Father, hypertension.,CURRENT MEDICATIONS: , Aspirin 81 mg daily.  She takes vitamins one a day.  She is on Zocor, Desyrel, Flonase, and Xanax.  She also has been taking Chantix for smoking cessation.,ALLERGIES: , Penicillin causes throat swelling.  She also notes the bee sting allergy causes throat and tongue swelling.,SOCIAL HISTORY: , The patient is single.  She is unemployed at this time.  She is a smoker about a pack and a half for 38 years and notes rare alcohol use.,PHYSICAL EXAMINATION:  ,VITAL SIGNS:  Her blood pressure 128/78, temperature is 98.6, pulse 80 and regular.,GENERAL:  The patient is an alert, cooperative, well-developed 51-year-old female.  She has a normal-sounding voice and good memory.,HEAD & FACE:  Inspected with no scars, lesions or masses noted.  Sinuses palpated and are normal.  Salivary glands also palpated and are normal with no masses noted.  The patient also has full facial function.,CARDIOVASCULAR:  Heart regular rate and rhythm without murmur.,RESPIRATORY:  Lungs auscultated and noted to be clear to auscultation bilaterally with no wheezing or rubs and normal respiratory effort.,EYES:  Extraocular muscles were tested and within normal limits.,EARS:  Right ear, the external ear is normal.  The ear canal is clean and dry.  The drum is intact.  She has got severe tympanosclerosis of the right tympanic membrane and Weber exam does lateralize to the right ear indicative of a conductive loss.  Left ear, the external ear is normal.  The ear canal is clean and dry.  The drum is intact and mobile with grossly normal hearing.  The audiogram does reveal normal hearing in the left ear.  She has got a mild conductive loss throughout all frequency ranges in the right ear with excellent discrimination scores noted bilaterally.  Tympanograms, there was no adequate seal obtained on the right side.  She has a normal type A tympanogram, left side.,NASAL:  Reveals a deviated nasal septum to the left, clear drainage, large inferior turbinates, no erythema.,ORAL:  Oral cavity is normal with good moisture.  Lips, teeth and gums are normal.  Evaluation of the oropharynx reveals normal mucosa, normal palates, and posterior oropharynx.  Examination of the larynx with a mirror reveals normal epiglottis, false and true vocal cords with good mobility of the cords.  The nasopharynx was briefly examined by mirror with normal appearing mucosa, posterior choanae and eustachian tubes.,NECK:  The neck was examined with normal appearance.  Trachea in the midline.  The thyroid was normal, nontender, with no palpable masses or adenopathy noted.,NEUROLOGIC:  Cranial nerves II through XII evaluated and noted to be normal.  Patient oriented times 3.,DERMATOLOGIC:  Evaluation reveals no masses or lesions.  Skin turgor is normal.,PROCEDURE: , Please note a fiberoptic laryngoscopy was also done at today's visit for further evaluation because of the patient's dysphagia and throat symptoms.  Findings do reveal moderately deviated nasal septum to the left, large inferior turbinates noted.  The nasopharynx does reveal moderate adenoid pad within this midline.  It is nonulcerated.  The larynx revealed both cords to be normal.  She does have mild lingual tonsillar hypertrophy as well.,IMPRESSION:  ,1.  Persistent dysphagia.  I think secondary most likely to the persistent postnasal drainage.,2.  Deviated nasal septum.,3.  Inferior turbinate hypertrophy.,4.  Chronic rhinitis.,5.  Conductive hearing loss, right ear with a history of cholesteatoma of the right ear.
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DESCRIPTION: Persistent dysphagia.  Deviated nasal septum.  Inferior turbinate hypertrophy.  Chronic rhinitis. Conductive hearing loss.  Tympanosclerosis.

The situation described involves a comprehensive ENT consultation for a patient with chronic conditions such as dysphagia, deviated nasal septum, and conductive hearing loss. While these symptoms can significantly affect the patient's quality of life, they do not immediately threaten the patient's survival or require urgent medical intervention. The assessment does not indicate acute or life-threatening conditions; hence it's more about managing chronic issues rather than immediate life or limb-saving actions. Thus, this situation is not extremely high-stakes medically, as it doesn't involve an emergency but rather ongoing management and evaluation.


Medical Specialty: ENT - Otolaryngology
Sample Name: Ear pain - Pediatric Consult

PRESENTATION: , Patient, 13 years old, comes to your office with his mother complaining about severe ear pain.  He awoke during the night with severe ear pain, and mom states that this is the third time this year he has had earaches.,HISTORY OF PRESENT ILLNESS:  ,Patient reports that he felt good after taking antibiotics with each earache episode and has recently started on the wrestling team.  Mom reports that patient has been afebrile with each of the earache episodes, and he has not had upper respiratory symptoms.  Patient denies any head trauma associated with wrestling practice.,BIRTH AND DEVELOPMENTAL HISTORY:,  Patient's mother reports a normal pregnancy with no complications, having received prenatal care from 12 weeks.  Vaginal delivery was uneventful with a normal perinatal course.  Patient sat alone at 6 months, crawled at 9 months, and walked at 13 months.  His verbal and motor developmental milestones were as expected.,FAMILY/SOCIAL HISTORY: , Patient lives with both parents and two siblings (brother - age 11 years, sister - age 15 years).  He reports enjoying school, remains active in scouts, and is very excited about being on the wresting team.  Mom reports that he has several friends, but she is concerned about the time required for the wrestling team.  Patient is in 8th grade this year and an A/B student.  Both siblings are healthy.  His Dad has hypertension and has frequent heartburn symptoms that he treats with over-the-counter (OTC) medications.  Mom is healthy and has asthma.,PAST MEDICAL HISTORY:  ,Patient has been seen in the clinic yearly for well child exams.  He has had no major illnesses or hospitalizations.  He had one emergency room visit 2 years ago for a knee laceration.  Patient has been healthy except for the past year when he had two episodes of otitis media not associated with respiratory infections.  He received antibiotic therapy (amoxicillin) for the otitis media and both episodes resolved without problems.  Patient's Mom states that he takes no prescribed medications or OTC medications, but he admits that he has been taking his dad's OTC Pepcid AE sometimes when he gets heartburn.  Upon further examination, he reports taking Pepcid when he eats pizza or Mexican food.  He does complain of sore throats sometimes and often feels burning in his throat when he goes to sleep at night after a late evening snack.,NUTRITIONAL HISTORY: , Patient eats cereal bars or pop tarts with milk for breakfast most days.  He takes his lunch (usually a sandwich and chips or yogurt and fruit) for lunch.  Mom or his sister cooks supper in the evening.  The family goes out to eat once or twice a week and he only gets "fast food" once or twice a week according to his Mom.  He says he eats "a lot" especially after a wrestling meet.,PHYSICAL EXAM:,Height/weight:  Patient weighs 109 pounds (60th percentile) and is 69 inches tall (93rd percentile).  He is following the growth pattern he established in infancy.,Vital signs:  BP 110/60, T 99.2, HR 70, R 16.,General:  Alert, cooperative but a bit shy.,Neuro:  DTRs symmetric, 2+, negative Romberg, able to perform simple calculations without difficulty, short-term memory intact.  He responds appropriately to verbal and visual cues, and movements are smooth and coordinated.,HEENT:  Normocephalic, PEERLA, red reflex present, optic disk and ocular vessels normal.  TMs deep red, dull, landmarks obscured, full bilaterally.  Post auricular and submandibular nodes on left are palpable and slightly tender.,Lungs:  CTA, breath sounds equal bilaterally, excursion and chest configuration normal.,Cardiac:  S1, S2 split, no murmurs, pulses equal bilaterally.,Abdomen:  Soft, rounded, reports no epigastric tenderness but states that heartburn begins in epigastric area and rises to throat.  Bowel sounds active in all quadrants.  No hepatosplenomegaly or tenderness.  No CVA tenderness.,Musculoskeletal:  Full range of motion, all extremities.  Spine straight, able to perform jumping jacks and duck walk without difficulty.,Genital:  Normal male, Tanner stage 4.  Rectal exam - small amount of soft stool, no fissures or masses.,LABS:  ,Stool negative for blood and H. pylori antigen.  Normal CBC and urinalysis.  A barium swallow and upper GI was scheduled for the following week.  It showed marked GE reflux.,ASSESSMENT: , The differential diagnoses for patient included (a) chronic otitis media/treatment failure, (b) peptic ulcer disease/gastritis, (c) gastro esophageal reflux disease (GERD) or carbonated beverage syndrome, (d) trauma.,CHRONIC OTITIS MEDIA. , Chronic otitis media due to a penicillin resistant organism would be the obvious diagnosis in this case.  It is rare for an adolescent to have otitis media with no precipitating factor (such as being on a swim team or otherwise exposed to unusual organisms or in an unusual environment).  It is certainly unusual for him to have three episodes in 1 year.,PEPTIC ULCER DISEASE.,  There were no symptoms of peptic ulcer disease, a negative H. pylori screen and lack of pain made this diagnosis less likely.  Trauma.  Trauma was a possibility, particularly since adolescent males frequently minimize symptoms especially if they might limit participation in a sport but patient maintained that he had not had an event where he struck his head or neck and that he always wore his helmet with ear padding.,GERD.,  The history of "heartburn" relieved by his father's medication was striking.  The positive study supported the diagnosis of GERD, which was severe and chronic enough to cause irritation of the mucosal surfaces exposed to the gastric juices and edema, inflammation in the inner ears.,PLAN:,  Patient and his Mom agreed to a trial of omeprazole 20 mg at bedtime for 2 weeks.  Patient was to keep a diary of any episodes of heartburn, including what foods seemed to aggravate it.  The clinician asked him to avoid using any antacid products in the meantime to gage the effectiveness of the medication.  He was also given a prescription for 10 days of Augmentin99 and a follow-up appointment for 2 weeks.  At his follow-up appointment he reported one episode after he ate a whole large pizza after wrestling practice but said it went away pretty quickly after he took his medication.  A 6-month follow up appointment was scheduled.
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DESCRIPTION: 13 years old complaining about severe ear pain - Chronic otitis media.

The situation involves a 13-year-old patient experiencing recurrent ear pain and possible chronic otitis media, potentially linked to severe GERD. While it requires medical attention and follow-up to address the underlying issues, it is a manageable condition with a treatment plan involving medication and dietary adjustments. There is no immediate life-threatening situation, but the frequency of symptoms and potential complications from untreated conditions like GERD should be addressed to prevent further issues, making it a moderate-stakes scenario.


Medical Specialty: ENT - Otolaryngology
Sample Name: Control of Parapharyngeal Hemorrhage

PREOPERATIVE DIAGNOSIS: , Postoperative hemorrhage.,POSTOPERATIVE DIAGNOSIS:,  Postoperative hemorrhage.,SURGICAL PROCEDURE:  ,Examination under anesthesia with control of right parapharyngeal space hemorrhage.,ANESTHESIA:  ,General endotracheal technique.,SURGICAL FINDINGS: , Right lower pole bleeder cauterized with electrocautery with good hemostasis.,INDICATIONS FOR SURGERY: , The patient is a 35-year-old female with a history of a chronic pharyngitis and obstructive adenotonsillar hypertrophy.  Previously, in the day she had undergone a tonsillectomy with adenoidectomy and was recovering without difficulty.  However, in the PACU after a coughing spell she began bleeding from the right oropharynx, and was taken back to the operative suite for control of hemorrhage.,DESCRIPTION OF SURGERY:  ,The patient was placed supine on the operating room table and general anesthetic was administered, once appropriate anesthetic findings achieved the patient was intubated and then prepped and draped in usual sterile manner for a parapharyngeal space hemorrhage.  A Crowe-Davis type mouth gag was introduced in the oropharynx and under operating headlight the oropharynx was clearly visualized.  There was a small bleeder present at the inferior mid pole of the right oropharynx in the tonsillar fossa, this area was cauterized with suction cautery and irrigated.  There was no other bleeding noted.  The patient was repositioned and the mouth gag, the tongue was rotated to the left side of the mouth and the right parapharyngeal space carefully examined.  There was a small amount of oozing noted in the right tonsillar bed, and this was cauterized with suction cautery.  No other bleeding was noted and the patient was recovered from general anesthetic.  She was extubated and left the operating room in good condition to postoperative recovery room area.  Prior to extubation the patient's tonsillar fossa were injected with a 6 mL of 0.25% Marcaine with 1:100,000 adrenalin solution to facilitate postoperative analgesia and hemostasis.
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DESCRIPTION: Postoperative hemorrhage. Examination under anesthesia with control of right parapharyngeal space hemorrhage.  The patient is a 35-year-old female with a history of a chronic pharyngitis and obstructive adenotonsillar hypertrophy.

ent - otolaryngology, obstructive adenotonsillar hypertrophy, tonsillar fossa, suction cautery, postoperative hemorrhage, parapharyngeal space, anesthesia, oropharynx, parapharyngeal, tonsillectomy, hemorrhage,

This scenario involves postoperative hemorrhage following a tonsillectomy and adenoidectomy, which can be a serious complication requiring urgent surgical intervention to control bleeding. Hemorrhage, especially in the oropharyngeal region, can potentially lead to significant blood loss, airway compromise, and other life-threatening issues if not promptly addressed. The need for a return to the operating room under general anesthesia to control the bleeding highlights the high-stakes nature of the situation. While the surgical team successfully managed the situation without further complications, the stakes of uncontrolled bleeding in such cases are inherently high.


Medical Specialty: ENT - Otolaryngology
Sample Name: Consult - Pulsatile Tinnitus

HISTORY: , The patient is a 48-year-old female who was seen in consultation requested from Dr. X on 05/28/2008 regarding chronic headaches and pulsatile tinnitus.  The patient reports she has been having daily headaches since 02/25/2008.  She has been getting pulsations in the head with heartbeat sounds.  Headaches are now averaging about three times per week.  They are generally on the very top of the head according to the patient.  Interestingly, she denies any previous significant history of headaches prior to this.  There has been no nausea associated with the headaches.  The patient does note that when she speaks on the phone, the left ear has "weird sounds."  She feels a general fullness in the left ear.  She does note pulsation sounds within that left ear only.  This began on February 17th according to the patient.  The patient reports that the ear pulsations began following an air flight to Iowa where she was visiting family.  The patient does admit that the pulsations in the ears seem to be somewhat better over the past few weeks.  Interestingly, there has been no significant drop or change in her hearing.  She does report she has had dizzy episodes in the past with nausea, being off balance at times.  It is not associated with the pulsations in the ear.  She does admit the pulsations will tend to come and go and there had been periods where the pulsations have completely cleared in the ear.  She is denying any vision changes.  The headaches are listed as moderate to severe in intensity on average about three to four times per week.  She has been taking Tylenol and Excedrin to try to control the headaches and that seems to be helping somewhat.  The patient presents today for further workup, evaluation, and treatment of the above-listed symptoms.,REVIEW OF SYSTEMS: , ,ALLERGY/IMMUNOLOGIC:  Negative.,CARDIOVASCULAR:  Hypercholesterolemia.,PULMONARY:  Negative.,GASTROINTESTINAL:  Pertinent for nausea.,GENITOURINARY:  The patient is noted to be a living kidney donor and has only one kidney.,NEUROLOGIC:  History of dizziness and the headaches as listed above.,VISUAL:  Negative.,DERMATOLOGIC:  History of itching.  She has also had a previous history of skin cancer on the arm and back.,ENDOCRINE:  Negative.,MUSCULOSKELETAL:  Negative.,CONSTITUTIONAL:  She has had an increased weight gain and fatigue over the past year.,PAST SURGICAL HISTORY:,  She has had a left nephrectomy, C-sections, mastoidectomy, laparoscopy, and T&A.,FAMILY HISTORY:,  Father, history of cancer, hypertension, and heart disease.,CURRENT MEDICATIONS: , Tylenol, Excedrin, and she is on multivitamin and probiotic's.,ALLERGIES: , She is allergic to codeine and penicillin.,SOCIAL HISTORY: , She is married.  She works at Eye Center as a receptionist.  She denies tobacco at this time though she was a previous smoker, stopped four years ago, and she denies alcohol use.,PHYSICAL EXAMINATION: , VITAL SIGNS:  Blood pressure 120/78, pulse 64 and regular, and the temperature is 97.4.,GENERAL:  The patient is an alert, cooperative, well-developed 48-year-old female with a normal-sounding voice and good memory.,HEAD & FACE:  Inspected with no scars, lesions or masses noted.  Sinuses palpated and are normal.  Salivary glands also palpated and are normal with no masses noted.  The patient also has full facial function.,CARDIOVASCULAR:  Heart regular rate and rhythm without murmur.,RESPIRATORY:  Lungs auscultated and noted to be clear to auscultation bilaterally with no wheezing or rubs and normal respiratory effort.,EYES:  Extraocular muscles were tested and within normal limits.,EARS:  There is an old mastoidectomy scar, left ear.  The ear canals are clean and dry.  Drums intact and mobile.  Weber exam is midline.  Grossly hearing is intact.  Please note audiologist not available at today's visit for further audiologic evaluation.,NASAL:  Reveals clear drainage.  Deviated nasal septum to the left, listed as mild to moderate.  Ostiomeatal complexes are patent and turbinates are healthy.  There was no mass or neoplasm within the nasopharynx noted on fiberoptic nasopharyngoscopy.  See fiberoptic nasopharyngoscopy separate exam.,ORAL:  Oral cavity is normal with good moisture.  Lips, teeth and gums are normal.  Evaluation of the oropharynx reveals normal mucosa, normal palates, and posterior oropharynx.  Examination of the larynx with a mirror reveals normal epiglottis, false and true vocal cords with good mobility of the cords.  The nasopharynx was briefly examined by mirror with normal appearing mucosa, posterior choanae and eustachian tubes.,NECK:  The neck was examined with normal appearance.  Trachea in the midline.  The thyroid was normal, nontender, with no palpable masses or adenopathy noted.,NEUROLOGIC:  Cranial nerves II through XII evaluated and noted to be normal.  Patient oriented times 3.,DERMATOLOGIC:  Evaluation reveals no masses or lesions.  Skin turgor is normal.,IMPRESSION:  ,1.  Pulsatile tinnitus, left ear with eustachian tube disorder as the etiology.  Consider, also normal pressure hydrocephalus.,2.  Recurrent headaches.,3.  Deviated nasal septum.,4.  Dizziness, again also consider possible Meniere disease.,RECOMMENDATIONS: , I did recommend the patient begin a 2 g or less sodium diet.  I have also ordered a carotid ultrasound study as part of the workup and evaluation.  She has had a recent CAT scan of the brain though this was without contrast.  It did reveal previous mastoidectomy, left temporal bone, but no other mass noted.  I have started her on Nasacort AQ nasal spray one spray each nostril daily as this is eustachian tube related.  Hearing protection devices should be used at all times as well.  I did counsel the patient if she has any upcoming airplane trips to use nasal decongestant or topical nasal decongestant spray prior to boarding the plane, and also using the airplane ear plugs as these can be effective at helping to prevent eustachian tube issues.  I am going to recheck her in three weeks.  If the pulsatile tinnitus at that time is not clear, we have discussed other treatment options including myringotomy or ear tube placement, which could be done here in the office.  She will be scheduled for a audio and tympanogram to be done as well prior to that procedure.
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DESCRIPTION: Chronic headaches and pulsatile tinnitus.

The patient's condition of pulsatile tinnitus and chronic headaches, while uncomfortable and potentially indicative of more serious underlying conditions, does not immediately suggest a life-threatening or severely debilitating issue. The recommended actions such as dietary adjustments, nasal spray, and the potential for myringotomy or ear tube placement imply management approaches that are relatively routine. However, the symptoms do warrant careful monitoring due to the potential for an underlying vascular issue given the pulsatile nature of the tinnitus. The situation is important, but not critically urgent from the information provided.


Medical Specialty: ENT - Otolaryngology
Sample Name: BMT & Adenoidectomy

PREOPERATIVE DIAGNOSIS: , Chronic otitis media.,POSTOPERATIVE DIAGNOSIS: , Chronic otitis media.,PROCEDURE PERFORMED: , Bilateral myringotomy tubes and adenoidectomy.,INDICATIONS FOR PROCEDURE:,  The patient is an 8-year-old child with history of recurrent otitis media.  The patient has had previous tube placement.  Tubes have since plugged and are no more functioning.  The patient has had recent recurrent otitis media.  Risks and benefits in terms of bleeding, anesthesia, and tympanic membrane perforation were discussed with the mother.  Mother wished to proceed with the surgery.,PROCEDURE IN DETAIL: , The patient was brought to the room, placed supine.  The patient was given general endotracheal anesthesia.  Starting on the left ear, under microscopic visualization, the ear was cleaned of wax.  A Bobbin tube was found stuck to the tympanic membrane.  This was removed.  After removing the tube the patient was found to have microperforation through which serous fluid was draining.  A fresh myringotomy was made in the anterior inferior quadrant.  More serous fluid was aspirated from middle ear space.  The new Bobbin tube was easily placed.  Floxin drops were placed in the ear.  In the right ear again under microscopic visualization, the ear was cleaned, the tube was removed off tympanic membrane.  There was no perforation seen; however, there was some granulation tissue on the surface of tympanic membrane.  A fresh myringotomy incision was made in the anterior inferior quadrant.  More serous fluid was drained out of middle ear space.  The tube was easily placed and Floxin drops were placed in the ear.  This completes tube portion of the surgery.  The patient was then turned and placed in the Rose position.  Shoulder roll was placed for neck extension.  Using a small McIvor mouth gag mouth was held open.  Using a rubber catheter the soft palate was retracted.  Under mirror visualization, the nasopharynx was examined.  The patient was found to have minimal adenoidal tissue.  This was removed using a suction Bovie.  The patient was then awakened from anesthesia, extubated and brought to recovery room in stable condition.  There were no intraoperative complications.  Needle and sponge count correct.  Estimated blood loss none.
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DESCRIPTION: Bilateral myringotomy tubes and adenoidectomy.

ent - otolaryngology, chronic otitis media, bilateral myringotomy tubes, adenoidectomy, myringotomy tubes and adenoidectomy, middle ear space, bilateral myringotomy, bobbin tube, fresh myringotomy, serous fluid, otitis media, tympanic membrane, tubes, myringotomy, otitis, media, membrane,

This situation involves an 8-year-old child undergoing a routine bilateral myringotomy and adenoidectomy. While surgeries on children can be considered sensitive due to their age and the requirement for general anesthesia, these procedures are generally considered low-risk and commonly performed, especially in cases of chronic otitis media. The case presented no complications, bleeding, or estimated blood loss, which further reduces the stakes. Thus, this situation would not be considered high-stakes from a medical perspective.


Medical Specialty: ENT - Otolaryngology
Sample Name: Adenotonsillectomy - 2

POSTOPERATIVE DIAGNOSIS:  Adenotonsillitis with hypertrophy.,OPERATION PERFORMED:  Adenotonsillectomy.,ANESTHESIA:  General endotracheal.,INDICATIONS:  The patient is a very nice patient with adenotonsillitis with hypertrophy and obstructive symptoms.  Adenotonsillectomy is indicated.,DESCRIPTION OF PROCEDURE:  The patient was placed on the operating room table in the supine position.  After adequate general endotracheal anesthesia was administered, table was turned and shoulder roll was placed on the shoulders and face was draped in clean fashion.  A McIvor mouth gag was applied.  The tongue was retracted anteriorly and the McIvor was gently suspended from a Mayo stand.  A red rubber Robinson catheter was inserted through the left naris and the soft palate was retracted superiorly.  The adenoids were removed with suction electrocautery under mere visualization.  The left tonsil was grasped with a curved Allis forceps, retracted medially and the anterior tonsillar pillar was incised with Bovie electrocautery.  The tonsil was removed from the superior and inferior pole using Bovie electrocautery in its entirety in the subcapsular fashion.  The right tonsil was grasped in the similar fashion and retracted medially and the anterior tonsillar pillar was incised with Bovie electrocautery.  The tonsil was removed from the superior pole and inferior pole using Bovie electrocautery in its entirety in the subcapsular fashion.  The inferior, middle and superior pole vessels were further cauterized with suction electrocautery.  Copious saline irrigation of the oral cavity was then performed.  There was no further identifiable bleeding at the termination of the procedure.  The estimated blood loss was less than 10 mL.  The patient was extubated in the operating room, brought to the recovery room in satisfactory condition.  There were no intraoperative complications.
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DESCRIPTION: Adenotonsillectomy.  Adenotonsillitis with hypertrophy.  The patient is a very nice patient with adenotonsillitis with hypertrophy and obstructive symptoms.  Adenotonsillectomy is indicated.

ent - otolaryngology, hypertrophy, adenotonsillitis, tonsillar pillar, bovie electrocautery, adenotonsillectomyNOTE,: 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.

Adenotonsillectomy is a common and routinely performed surgical procedure, particularly in children, to treat chronic tonsillitis and adenoiditis. While it requires general anesthesia and a sterile environment, it's generally considered low-risk and straightforward with a high success rate. Postoperative complications are rare but can include bleeding or infection. The procedure described was uneventful with no complications, indicating a routine surgical case.


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

PREOPERATIVE DIAGNOSIS: , Adenoid hypertrophy.,POSTOPERATIVE DIAGNOSIS: , Adenoid hypertrophy.,PROCEDURE PERFORMED:  ,Adenoidectomy.,ANESTHESIA: , General endotracheal.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room and prepped and draped in the usual fashion after induction of general endotracheal anesthesia.  The McIvor mouth gag was placed in the oral cavity and the tongue depressor applied.  Two #12-French red rubber Robinson catheters were placed, 1 in each nasal passage, and brought out through the oral cavity and clamped over a dental gauze roll placed on the upper lip to provide soft palate retraction.  The nasopharynx was inspected with the laryngeal mirror.  Serial passages of the curettes were utilized to remove the nasopharyngeal tissue, following which the nasopharynx was packed with 2 cherry gauze sponges coated in a solution of 0.25% Neo-Synephrine and tannic acid powder.,Attention was then redirected to the oropharynx.  The McIvor was reopened, packs removed, and the bleeding was controlled with the suction Bovie unit.  The catheters were removed, and the nasal passages and oropharynx were suctioned free of debris.  The McIvor was then removed, and the procedure was terminated.,The patient tolerated the procedure well and left the operating room in good condition.
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DESCRIPTION: Adenoidectomy.  Adenoid hypertrophy.  The McIvor mouth gag was placed in the oral cavity and the tongue depressor applied.

ent - otolaryngology, palate, nasal passage, mcivor mouth gag, oral cavity, nasal, nasopharynx, oropharynx, hypertrophy, oral, cavity, mcivor, tongue, adenoidectomy

An adenoidectomy is a common surgical procedure often performed on children to remove adenoid tissue when it's causing health issues like chronic ear infections or breathing problems. While surgery always carries some level of risk due to anesthesia and potential complications, this procedure is generally considered routine for ENT specialists. The description indicates that the patient tolerated the procedure well and left the operating room in good condition, suggesting there were no immediate complications. Thus, while it is a surgical procedure, it doesn't involve critical life-or-death outcomes typical of high-stakes situations.


Medical Specialty: ENT - Otolaryngology
Sample Name: Adenoidectomy

ADENOIDECTOMY,PROCEDURE:,  The patient was brought into the operating room suite, anesthesia administered via endotracheal tube.  Following this the patient was draped in standard fashion.  The Crowe-Davis mouth gag was inserted in the oral cavity.  The palate and tonsils were inspected, the palate was suspended with a red rubber catheter passed through the right nostril.  Following this, the mirror was used to visualize the adenoid pad and an adenoid curet was seated against the vomer.  The adenoid pad was removed without difficulty.  The nasopharynx was packed.  Following this, the nasopharynx was unpacked, several discrete bleeding sites were gently coagulated with electrocautery and the nasopharynx and oral cavity were irrigated.  The Crowe-Davis was released.,The patient tolerated the procedure without difficulty and was in stable condition on transfer to recovery.
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DESCRIPTION: Adenoidectomy procedure

Adenoidectomy procedure

ent - otolaryngology, adenoidectomy, crowe-davis, adenoid pad, electrocautery, endotracheal tube, gently coagulated, mouth gag, nasopharynx, oral cavity, red rubber catheter, vomer, palate, tonsilsNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

The situation involves an adenoidectomy procedure, which is a common surgical operation conducted by ENT specialists to remove adenoid tissue. While it is generally considered a routine and low-risk procedure, especially for a trained medical team, there are always inherent risks associated with anesthesia and surgery. The description indicates that the procedure went smoothly, with the patient stable post-operation, suggesting a successful outcome. Given the standard nature of the procedure and its successful execution, it would not be classified as a high-stakes situation under typical circumstances.


Medical Specialty: ENT - Otolaryngology
Sample Name: Bilateral Myringotomies - 1

PREOPERATIVE DIAGNOSES:,  OM, chronic, serous, simple or unspecified.  Adenoid hyperplasia.  Hypertrophy of tonsils.,POSTOPERATIVE DIAGNOSIS: , Same as preoperative diagnosis.,OPERATION: , Bilateral myringotomies with Armstrong grommet tubes, Adenoidectomy, and Tonsillectomy.,ANESTHESIA:,  General.,COMPLICATIONS:,  None.,ESTIMATED BLOOD LOSS: , Minimal.,DRAINS: , None.,CONSENT:,  The procedure, benefits, and risks were discussed in detail preoperatively.  The parentsagreed to proceed after all questions were answered.,TECHNIQUE: , The patient was brought to the operating room and placed in the supine position.  After general mask anesthesia was adequately obtained, the right external auditory canal was cleaned out under the microscope.  Serous fluid was aspirated from the middle ear space.  An Armstrong grommet tube was placed down through the incision and rotated into place.  The opposite ear was then cleaned out under the microscope.  Serous fluid was aspirated from the middle ear space.  An Armstrong grommet tube was placed down through the incision and rotated into place.  Cortisporin suspension was placed in both ear canals.,Then the patient was intubated.  A Crowe-Davis mouth gag was placed into the mouth and extended and hung on the Mayo stand.  The red rubber catheter was placed down through the nose and brought out through the mouth to retract the palate.  The adenoid fossa was visualized with the mirror.  The adenoids were removed using the microdebrider.  Two adenoid packs were placed.  The packs were removed one by one.  Using mirror and suction bovie, adequate hemostasis was achieved.,The tonsils were quite large and cryptic.  The tenaculum was placed on the superior pole of the right tonsil.  Cheesy material came out from the crypts.  The tonsils were retracted medially.  The bovie electrocautery was used to make an incision in the right anterior tonsillar pillar, and the plane was developed between the tonsil and the musculature.  The tonsil was completely dissected out of this plane, preserving both the anterior and posterior tonsillar pillars.  All bleeders were cauterized as they were encountered.  The tenaculum was then placed on the superior pole of the left tonsil.  Cheesy material came out from the crypts.  The tonsils were retracted medially.  The bovie electrocautery was used to make an incision in the left anterior tonsillar pillar, and the plane was developed between the tonsil and the musculature.  The tonsil was completely dissected out of this plane, preserving both the anterior and posterior tonsillar pillars.  All bleeders were cauterized as they were encountered.  Both tonsil beds were then re-cauterized, paying particular attention to the inferior and superior poles.,The stomach was evacuated with the nasogastric tube.  The patient was then awakened in the operating room, extubated and taken to the recovery room in satisfactory condition.
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DESCRIPTION: Bilateral myringotomies with Armstrong grommet tubes, Adenoidectomy, and Tonsillectomy.

ent - otolaryngology, adenoid hyperplasia, om, adenoidectomy, tonsillectomy, auditory canal, serous fluid, crowe-davis mouth gag, tonsils, adenoidectomy and tonsillectomy, armstrong grommet tubes, bovie electrocautery, tonsillar pillar, bilateral myringotomies, armstrong, tubes, grommet, tonsillar, bilateral, myringotomies, tenaculum

The procedure described involves a common set of surgeries performed in otolaryngology to address chronic middle ear infections and conditions such as adenoid hyperplasia and tonsil hypertrophy. While the operation involves general anesthesia and has inherent risks associated with surgical procedures, it is relatively routine and typically has minimal complications, as indicated in the sample. The described procedure had no complications and minimal blood loss, suggesting a successful and typical outcome. Consent was properly obtained, and the patient was in satisfactory condition post-surgery. While any surgery carries some risk, especially under general anesthesia, this particular procedure's routine nature and the absence of complications suggest it is not extremely high-stakes.


Medical Specialty: ENT - Otolaryngology
Sample Name: Adenoidectomy & Tonsillectomy & Lingual Frenulectomy

PREOPERATIVE DIAGNOSES:,1.  Chronic adenotonsillitis.,2.  Ankyloglossia,POSTOPERATIVE DIAGNOSES:,1.  Chronic adenotonsillitis.,2.  Ankyloglossia,PROCEDURE PERFORMED:,1.  Adenoidectomy and tonsillectomy.,2.  Lingual frenulectomy.,ANESTHESIA: , General endotracheal.,FINDINGS/SPECIMEN:,  Tonsil and adenoid tissue.,COMPLICATIONS: , None.,CONDITION:  ,The patient is stable and tolerated the procedure well, and sent to PACU.,HISTORY OF PRESENT ILLNESS: , This is a 3-year-old child with a history of adenotonsillitis.,PROCEDURE: , The patient was prepped and draped in the usual sterile fashion.  A curved hemostat was used to grasp the lingual frenulum.  The stat was removed and Metzenbaum scissors were used to free the lingual frenulum.  Cautery was used to allow hemostasis.  The patient was then turned.  McIvor mouth gag was inserted.  Tonsils and adenoids were exposed.  The patient's right tonsil was first grasped with a curved hemostat.  Needle tip cautery was used to free the superior pole of tonsil.  The tonsil was then grasped in medial superior aspect with a straight hemostat.  The tonsil fascia planes were identified with Bovie dissection along the plane.  The tonsil was freed from anterior pillar and posterior pillar.  Amputation occurred along the same plane as the patient's tongue.  Suction cautery was then used to allow for hemostasis.  The patient's adenoids were then viewed with an adenoid mirror.  An adenoid curet was used to remove the patient's adenoid tissue.  Specimen sent.  Suction cautery was used to allow for hemostasis.  Superior pole of left tonsil was then grasped with a curved hemostat.  Superior pole was freed using needle tip Bovie dissection.  Beginning with 15 desiccate, after superior pole was free, Bovie was switched to 15 fulgurate, and the tonsil was stripped from anterior and posterior pillars.  The tonsil was then amputated at the same plane as tongue base.  Hemostasis was achieved with using suction cautery.  Mouth gag was removed.  Dual position and occlusion were tested.  The patient was extubated and tolerated the procedure well and sent back to PACU.
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DESCRIPTION: Adenoidectomy and tonsillectomy and lingual frenulectomy.   Chronic adenotonsillitis and ankyloglossia.

ent - otolaryngology, adenotonsillitis, ankyloglossia, adenoidectomy, tonsillectomy, frenulectomy, tonsil, adenoid tissue, metzenbaum scissors, lingual frenulectomy, chronic adenotonsillitis, curved hemostat, suction cautery, hemostat, hemostasis, lingual, cautery

The scenario involves a common surgical procedure (adenotonsillectomy and lingual frenulectomy) on a 3-year-old child. These procedures are generally routine and have low complication rates, especially when performed by experienced professionals in a controlled setting. The report indicates no complications, and the patient is stable, suggesting that the operation went smoothly. While any medical procedure on a child requires careful attention, this does not constitute a high-stakes situation given the context provided.


Medical Specialty: Endocrinology
Sample Name: Thyroidectomy

TITLE OF OPERATION:  ,Total thyroidectomy for goiter.,INDICATION FOR SURGERY:  ,This is a 41-year-old woman who notes that compressive thyroid goiter and symptoms related to such who wishes to undergo surgery.  Risks, benefits, alternatives of the procedures were discussed in great detail with the patient.  Risks include but were not limited to anesthesia, bleeding, infection, injury to nerve, vocal fold paralysis, hoarseness, low calcium, need for calcium supplementation, tumor recurrence, need for additional treatment, need for thyroid medication, cosmetic deformity, and other.  The patient understood all these issues and they wished to proceed.,PREOP DIAGNOSIS: , Multinodular thyroid goiter with compressive symptoms and bilateral dominant thyroid nodules proven to be benign by fine needle aspiration.,POSTOP DIAGNOSIS: , Multinodular thyroid goiter with compressive symptoms and bilateral dominant thyroid nodules proven to be benign by fine needle aspiration.,ANESTHESIA: , General endotracheal.,PROCEDURE DETAIL: , After identifying the patient, the patient was placed supine in a operating room table.  After establishing general anesthesia via oral endotracheal intubation with a 6 Nerve Integrity monitoring system endotracheal tube.  The eyes were then tacked with Tegaderm.  The Nerve Integrity monitoring system, endotracheal tube was confirmed to be working adequately.  Essentially a 7 cm incision was employed in the lower skin crease of the neck.  A 1% lidocaine with 1:100,000 epinephrine were given.  Shoulder roll was applied.  The patient prepped and draped in a sterile fashion.  A 15-blade was used to make the incision.  Subplatysmal flaps were raised to the thyroid notch and sternal respectively.  The strap muscles were separated in the midline.  As we then turned to the left side where the sternohyoid muscle was separated from the sternothyroid muscle there was a very dense and firm thyroid mass on the left side.  The sternothyroid muscle was transected horizontally.  Similar procedure was performed on the right side.,Attention was then turned to identify the trachea in the midline.  Veins in this area and the pretracheal region were ligated with a harmonic scalpel.  Subsequently, attention was turned to dissecting the capsule off of the left thyroid lobe.  Again this was very firm in nature.  The superior thyroid pole was dissected in the superior third artery, vein, and the individual vessels were ligated with a harmonic scalpel.  The inferior and superior parathyroid glands were protected.  Recurrent laryngeal nerve was identified in the tracheoesophageal groove.  This had arborized early as a course underneath the inferior thyroid artery to a very small tiny anterior motor branch.  This was followed superiorly.  The level of cricothyroid membrane upon complete visualization of the entire nerve, Berry's ligament was transected and the nerve protected and then the thyroid gland was dissected over the trachea.  A prominent pyramidal level was also appreciated and dissected as well.,Attention was then turned to the right side.  There was significant amount of thyroid tissue that was very firm.  Multiple nodules were appreciated.  In a similar fashion, the capsule was dissected.  The superior and inferior parathyroid glands protected and preserved.  The superior thyroid artery and vein were individually ligated with the harmonic scalpel and the inferior thyroid artery was then ligated close to the thyroid gland capsule.  Once the recurrent laryngeal nerve was identified again on this side, the nerve had arborized early prior to the coursing underneath the inferior thyroid artery.  The anterior motor branch was then very fine, almost filamentous and stimulated at 0.5 milliamps, completely dissected toward the cricothyroid membrane with complete visualization.  A small amount of tissue was left at the Berry's ligament as the remainder of thyroid level was dissected over the trachea.  The entire thyroid specimen was then removed, marked with a stitch upon the superior pole.  The wound was copiously irrigated, Valsalva maneuver was given, bleeding points controlled.  The parathyroid glands appeared to be viable.  Both the anterior motor branches that were tiny were stimulated at 5 milliamps and confirmed to be working with the Nerve Integrity monitoring system.,Attention was then turned to burying the Surgicel on the wound bed on both sides.  The strap muscles were reapproximated in the midline using a 3-0 Vicryl suture of the sternothyroid horizontal transection and the strap muscles in the midline were then reapproximated.  The 1/8th inch Hemovac drain was placed and secured with a 3-0 nylon.  The incision was then closed with interrupted 3-0 Vicryl and Indermil for the skin.  The patient has a history of keloid formation and approximately 1 cubic centimeter of 40 mg per cubic centimeter Kenalog was injected into the incisional line using a tuberculin syringe and 25-gauge needle.  The patient tolerated the procedure well, was extubated in the operating room table, and sent to postanesthesia care unit in a good condition.  Upon completion of the case, fiberoptic laryngoscopy revealed intact bilateral true vocal fold mobility.
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DESCRIPTION: Total thyroidectomy for goiter.  Multinodular thyroid goiter with compressive symptoms and bilateral dominant thyroid nodules proven to be benign by fine needle aspiration.

endocrinology, total thyroidectomy, goiter, multinodular thyroid goiter, multinodular, thyroid nodules, parathyroid glands, thyroid goiter, thyroid artery, thyroidectomy

A total thyroidectomy is a significant surgical procedure that involves removing the entire thyroid gland to treat a multinodular goiter, even though the nodules are benign. The potential risks associated with this surgery, including vocal fold paralysis, low calcium levels, and the need for lifelong thyroid medication, make it a relatively high-stakes situation. The thorough preparation and postoperative care detailed in the document also suggest the importance of preventing complications, emphasizing the serious nature of the procedure. While the patient tolerated the procedure well, and it was not an emergency surgery, the long-term implications and risks involved in the operation contribute to its high-stakes nature.


Medical Specialty: Endocrinology
Sample Name: Hyperthyroidism Following Pregnancy

HISTORY: , Patient is a 21-year-old white woman who presented with a chief complaint of chest pain.  She had been previously diagnosed with hyperthyroidism.  Upon admission, she had complaints of constant left sided chest pain that radiated to her left arm.  She had been experiencing palpitations and tachycardia.  She had no diaphoresis, no nausea, vomiting, or dyspnea.,She had a significant TSH of 0.004 and a free T4 of 19.3.  Normal ranges for TSH and free T4 are 0.5-4.7 µIU/mL and 0.8-1.8 ng/dL, respectively.  Her symptoms started four months into her pregnancy as tremors, hot flashes, agitation, and emotional inconsistency.  She gained 16 pounds during her pregnancy and has lost 80 pounds afterwards.  She complained of sweating, but has experienced no diarrhea and no change in appetite.  She was given isosorbide mononitrate and IV steroids in the ER.,FAMILY HISTORY:,  Diabetes, Hypertension, Father had a Coronary Artery Bypass Graph (CABG) at age 34.,SOCIAL HISTORY:,  She had a baby five months ago.  She smokes a half pack a day.  She denies alcohol and drug use.,MEDICATIONS:,  Citalopram 10mg once daily for depression; low dose tramadol PRN pain.,PHYSICAL EXAMINATION: , Temperature 98.4; Pulse 123; Respiratory Rate 16; Blood Pressure 143/74.,HEENT:  She has exophthalmos and could not close her lids completely.,Cardiovascular:  tachycardia.,Neurologic:  She had mild hyperreflexiveness.,LAB:,  All labs within normal limits with the exception of Sodium 133, Creatinine 0.2, TSH 0.004, Free T4 19.3 EKG showed sinus tachycardia with a rate of 122.  Urine pregnancy test was negative.,HOSPITAL COURSE: , After admission, she was given propranolol at 40mg daily and continued on telemetry.  On the 2nd day of treatment, the patient still complained of chest pain.  EKG again showed tachycardia.  Propranolol was increased from 40mg daily to 60mg twice daily., A I-123 thyroid uptake scan demonstrated an increased thyroid uptake of 90% at 4 hours and 94% at 24 hours.  The normal range for 4-hour uptake is 5-15% and 15-25% for 24-hour uptake.  Endocrine consult recommended radioactive I-131 for treatment of Graves disease.,Two days later she received 15.5mCi of I-131.  She was to return home after the iodine treatment.  She was instructed to avoid contact with her baby for the next week and to cease breast feeding.,ASSESSMENT / PLAN:,1. Treatment of hyperthyroidism.  Patient underwent radioactive iodine 131 ablation therapy.,2. Management of cardiac symptoms stemming from hyperthyroidism.  Patient was discharged on propranolol 60mg, one tablet twice daily.,3. Monitor patient for complications of I-131 therapy such as hypothyroidism.  She should return to Endocrine Clinic in six weeks to have thyroid function tests performed.  Long-term follow-up includes thyroid function tests at 6-12 month intervals.,4. Prevention of pregnancy for one year post I-131 therapy.  Patient was instructed to use 2 forms of birth control and was discharged an oral contraceptive, taken one tablet daily.,5. Monitor ocular health.  Patient was given methylcellulose ophthalmic, one drop in each eye daily.  She should follow up in 6 weeks with the Ophthalmology clinic.,6. Management of depression.  Patient will be continued on citalopram 10 mg.
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DESCRIPTION: Chief complaint of chest pain, previously diagnosed with hyperthyroidism.

endocrinology, hyperthyroidism, diabetes, hypertension, hospital course, thyroid function, tachycardia, pregnancy,

The situation involves a 21-year-old woman with a significant medical condition, hyperthyroidism, particularly following pregnancy. The stakes are moderate because hyperthyroidism can lead to complications like cardiac issues, which she is experiencing in the form of tachycardia and chest pain. However, the condition is being actively managed with appropriate treatment interventions (propranolol, radioactive iodine), and the plan includes close follow-up care. This makes the scenario not extremely high-stakes but moderately urgent considering the potential impacts on her health and quality of life, as well as its complexity regarding her recent pregnancy and need for postpartum care.


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

Medical Specialty: Endocrinology
Sample Name: Metastatic Lymphadenopathy & Thyroid Tissue Removal

TITLE OF OPERATION: , Central neck reoperation with removal of residual metastatic lymphadenopathy and thyroid tissue in the central neck.  Left reoperative neck dissection levels 1 and the infraclavicular fossa on the left side.  Right levels 2 through 5 neck dissection and superior mediastinal dissection of lymph nodes and pretracheal dissection of lymph nodes in a previously operative field.,INDICATION FOR SURGERY: , The patient is a 37-year-old gentleman well known to me with a history of medullary thyroid cancer sporadic in nature having undergone surgery in 04/07 with final pathology revealing extrafocal, extrathyroidal extension, and extranodal extension in the soft tissues of his medullary thyroid cancer.  The patient had been followed for a period of time and underwent rapid development of a left and right infraclavicular lymphadenopathy and central neck lymphadenopathy also with imaging studies to suggest superior mediastinal disease.  Fine-needle aspiration of the left and right infraclavicular lymph nodes revealed persistent medullary thyroid cancer.  Risks, benefits, and alternatives of the procedures discussed with in detail and the patient elected to proceed with surgery as discussed.  The risks included, but not limited to anesthesia, bleeding, infection, injury to nerve, lip, tongue, shoulder, weakness, tongue numbness, droopy eyelid, tumor comes back, need for additional treatment, diaphragm weakness, pneumothorax, need for chest tube, others.  The patient understood all these issues and did wish to proceed.,PROCEDURE DETAIL:  ,After identifying the patient, the patient was placed supine on the operating room table.  The patient was intubated with a number 7 nerve integrity monitor system endotracheal tube.  The eyes were protected with Tegaderm.  The patient was rotated to 180 degrees towards the operating surgeon.  The Foley catheter was placed into the bladder with good return of urine.  Attention then was turned to securing the nerve integrity monitor system endotracheal tube and this was confirmed to be working adequately.  A previous apron incision was incorporated and advanced over onto the right side to the mastoid tip.  The incision then was planned around the old scar to be excised.  A 1% lidocaine with 1 to 100,000 epinephrine was injected.  A shoulder roll was applied.  The incision was made, the apron flap was raised to the level of the mandible and mastoid tip bilaterally all the way down to the clavicle and sternal notch inferiorly.  Attention was then turned to performing the level 1 dissection on the left.  Subsequently the marginal mandibular nerve was identified over the facial notch of the mandible.  The facial artery and vein were individually ligated and marginal mandibular nerve traced superiorly and perifascial lymph nodes freed from the marginal mandibular nerve.  Level 1A lymph nodes of the submental region were dissected off the mylohyoid and digastric.  The submandibular gland was appreciated and retracted laterally.  The mylohyoid muscle appreciated.  The lingual nerve was appreciated and the submandibular ganglion was ligated.  The hypoglossal nerve was appreciated and protected and digastric tunnel was then made posteriorly and the lymph nodes posterior along the marginal mandibular nerve and into the parotid gland were then dissected and incorporated into the specimen for histopathologic analysis.  The marginal mandibular nerve stimulated at the completion of this portion of the procedure.  Attention was then turned to incising the fascia along the clavicle on the left side.  Dissection then ensued along the floor of the neck palpating a very large bulky lymph node before the neck was identified.  The brachial plexus and phrenic nerve were identified.  The internal jugular vein identified and the mass was freed from the floor of the neck with careful dissection and suture ligation of vessels.  Attention was then turned to the central neck.  The strap muscles were appreciated in the midline.  There was a large firm mass measuring approximately 3 cm that appeared to be superior to the strap musculature.  A careful dissection with incorporation of a portion of the sternal hyoid muscle in this area for a margin was then performed.  Attention was then turned to identify the carotid artery and the internal jugular vein on the left side.  This was traced inferiorly, internal jugular vein to the brachiocephalic vein.  Palpation deep to this area into the mediastinum and up against the trachea revealed a 1.5 cm lymph node mass.  Subsequently this was carefully dissected preserving the brachiocephalic vein and also the integrity of the trachea and the carotid artery and these lymph nodes were removed in full and sent for histopathologic analysis.  Attention was then turned to the right neck dissection.  A posterior flap on the right was raised to the anterior border of the trapezius.  The accessory nerve was identified in the posterior triangle and traced superiorly and inferiorly.  Attention was then turned to identifying the submandibular gland.  A digastric tunnel was performed back to the sternocleidomastoid muscle.  The fascia overlying the sternocleidomastoid muscle on the right side was incised and the omohyoid muscle was appreciated.  The omohyoid muscle was retracted inferiorly.  Penrose drain was placed around the inferior aspect of the sternocleidomastoid muscle.  Subsequently the internal jugular vein was identified.  The external jugular vein ligated about 1 cm above the clavicle.  Palpation in this area and the infraclavicular region on the right revealed a firm irregular lymph node complex.  Dissection along the floor of the neck then was performed to allow for mobilization.  The transverse cervical artery and vein were individually ligated to allow full mobilization of this mass.  Tissue between the phrenic nerve and the internal jugular vein was clamped and suture ligated.  The tissue was then brought posteriorly from the trapezius muscle to the internal jugular vein and traced superiorly.  The cervical rootlets were transected after the contribution, so the phrenic nerve all the way superiorly to the skull base.  The hypoglossal nerve was identified and protected as the lymph node packet was dissected over the internal jugular vein.  The wound was copiously irrigated.  Valsalva maneuver was given.  No bleeding points identified.  The wound was then prepared for closure.  Two number 10 JPs were placed through the left supraclavicular fossa in the previous drain sites and secured with 3-0 nylon.  The wound was closed  with interrupted 3-0 Vicryl for platysma, subsequently a 4-0 running Biosyn for the skin, and Indermil.  The patient tolerated the procedure well, was extubated on the operating room table, and sent to the postanesthesia care unit in good condition.
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DESCRIPTION: Central neck reoperation with removal of residual metastatic lymphadenopathy and thyroid tissue in the central neck.   Left reoperative neck dissection levels 1 and the infraclavicular fossa on the left side.  Right levels 2 through 5 neck dissection and superior mediastinal dissection of lymph nodes and pretracheal dissection of lymph nodes in a previously operative field.

endocrinology, lymphadenopathy, thyroid, infraclavicular, fossa, lymph nodes, dissection, pretracheal, internal jugular vein, infraclavicular lymphadenopathy, metastatic lymphadenopathy, mandibular nerve, vein, nodes, neck, nerve, muscle, jugularNOTE

The situation involves a complex surgical procedure for a patient with recurrent medullary thyroid cancer, which is life-threatening if not treated. The operation entails significant risks and complications such as nerve injury, bleeding, infection, and potential for the cancer to recur, highlighting its critical nature. Successful surgery can significantly impact the patient's prognosis and quality of life, making it high-stakes.


Medical Specialty: Emergency Room Reports
Sample Name: Viral Syndrome - ER Visit

SUBJECTIVE:  ,This 68-year-old man presents to the emergency department for three days of cough, claims that he has brought up some green and grayish sputum.  He says he does not feel short of breath.  He denies any fever or chills.,REVIEW OF SYSTEMS:,HEENT:  Denies any severe headache or sore throat.,CHEST:  No true pain.,GI:  No nausea, vomiting, or diarrhea.,PAST HISTORY:,  He states that he is on Coumadin because he had a cardioversion done two months ago for atrial fibrillation.  He also lists some other medications.  I do have his medications list.  He is on Pacerone, Zaroxolyn, albuterol inhaler, Neurontin, Lasix, and several other medicines.  Those are the predominant medicines.  He is not a diabetic.  The past history otherwise, he has had smoking history, but he quit several years ago and denies any COPD or emphysema.  No one else in the family is sick.,PHYSICAL EXAMINATION:,GENERAL:  The patient appears comfortable.  He did not appear to be in any respiratory distress.  He was alert.  I heard him cough once during the entire encounter.  He did not bring up any sputum at that time.,VITAL SIGNS:  His temperature is 98, pulse 71, respiratory rate 18, blood pressure 122/57, and pulse ox is 95% on room air.,HEENT:  Throat was normal.,RESPIRATORY:  He was breathing normally.  There was clear and equal breath sounds.  He was speaking in full sentences.  There was no accessory muscle use.,HEART:  Sounded regular.,SKIN:  Normal color, warm and dry.,NEUROLOGIC:  Neurologically he was alert.,IMPRESSION: , Viral syndrome, which we have been seeing in many cases throughout the week.  The patient asked me about antibiotics and I did not see a need to do this since he did not appear to have an infection other than viral given his normal temperature, normal pulse, normal respiratory rate, and near normal oxygen.  The patient being on Coumadin I explained to him that unless there was a solid reason to put him on antibiotics, he would be advised not to do so because antibiotics can alter the gut floor causing the INR to increase while on Coumadin which may cause serious bleeding.  The patient understands this.  I then asked him if the cough was annoying him, he said it was.  I offered him a cough syrup, which he agreed to take.  The patient was then discharged with Tussionex Pennkinetic a hydrocodone time-release cough syrup.  I told to check in three days, if the symptoms were not getting better.  The patient appeared to be content with this treatment and was discharged in approximately 30 to 45 minutes later.  His wife calls me very angry that I did not give him antibiotics.  I explained her exactly what I explained to him that they were not indicative at this time, and she became very upset saying that they came there specifically for antibiotics and I explained again that antibiotics are not indicated for viral infection and that I did not think he had a bacterial infection.,DIAGNOSIS: , Viral respiratory illness.
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DESCRIPTION: This 68-year-old man presents to the emergency department for three days of cough, claims that he has brought up some green and grayish sputum.  He says he does not feel short of breath.  He denies any fever or chills.

emergency room reports, sputum, short of breath, fever, chills, copd, emphysema, viral respiratory illness, green and grayish sputum, viral syndrome, respiratory rate, cough syrup, cough, antibiotics, inhaler,

The scenario involves a 68-year-old patient with a cough and some sputum production, but no other severe symptoms such as fever, shortness of breath, or respiratory distress. His vital signs are stable and there is a working diagnosis of a viral syndrome, for which antibiotics are not indicated. The patient's use of Coumadin adds a layer of complexity due to potential bleeding risks if antibiotics were prescribed unnecessarily, but this has been assessed and managed by the medical practitioner. The situation could escalate if not monitored, but the patient has been advised to return if symptoms persist or worsen. This mitigates the immediate high-stakes nature of the situation. It is primarily a common viral condition that has been appropriately addressed within the ER context, leading to a low-to-moderate stakes assessment due to the age and medication use of the patient.


Medical Specialty: Endocrinology
Sample Name: Completion Thyroidectomy

TITLE OF OPERATION:,  Completion thyroidectomy with limited right paratracheal node dissection.,INDICATION FOR SURGERY:,  A 49-year-old woman with a history of a left dominant nodule in her thyroid gland, who subsequently underwent left thyroid lobectomy and isthmusectomy, was found to have multifocal papillary thyroid carcinoma throughout her left thyroid lobe and isthmus.  Consideration given to completion thyroidectomy.  Risks, benefits, and alternatives of this procedure was discussed with the patient in great detail.  Risks included but were not limited to anesthesia, bleeding, infection, injury to nerves including vocal fold paralysis, hoarseness, low calcium, scar, cosmetic deformity, need for thyroid hormone replacement, and also need for further management.  The patient understood all of this and then wished to proceed.,PREOP DIAGNOSIS:,  Multifocal thyroid carcinoma and previous left thyroid lobectomy resection specimen.,POSTOP DIAGNOSIS: , Multifocal thyroid carcinoma and previous left thyroid lobectomy resection specimen.,PROCEDURE DETAIL:,  After identifying the patient, the patient was placed supine in the operating room table.  After establishment of general anesthesia via orotracheal intubation with a number 6 nerve integrity monitoring system endotracheal tube, the eyes were protected with Tegaderm.  Nerve integrity monitoring system endotracheal tube was confirmed to be working adequately and secured.  The previous skin incision for a thyroidectomy was then planned, then incorporated into an ellipse.  The patient was prepped and draped in a sterile fashion.  Subsequently, the ellipse around the previous incision was deformed.  The scar was then excised.  Subplatysmal flaps were raised to the thyroid notch and sternal notch respectively.  Strap muscles were isolated in the midline and dissected and mobilized from the thyroid lobe on the right side.  There was some dense fibrosis and inflammation surrounding the right thyroid lobe.  Careful dissection along the thyroid lobe allowed for identification of the superior thyroid artery and vein which were individually ligated with a Harmonic scalpel.  The right inferior and superior parathyroid glands were identified and preserved and recurrent laryngeal nerve was identified and traced superiorly, then preserved.  Of note is that there were multiple lymph nodes in the paratracheal region on the right side.  These lymph nodes were carefully dissected away from the recurrent laryngeal nerve, trachea, and the carotid artery, and sent as a separate specimen labeled right paratracheal lymph nodes.  The wound was copiously irrigated.  Valsalva maneuver was given.  Surgicel was placed in the wound bed.  Strap muscles were reapproximated in the midline with 3-0 Vicryl and incision was then closed with interrupted 3-0 Vicryl and Indermil for the skin.  The patient was extubated in the operating room table, sent to the postanesthesia care unit in good condition.
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DESCRIPTION: Completion thyroidectomy with limited right paratracheal node dissection.

endocrinology, multifocal thyroid carcinoma, thyroid lobectomy, thyroid, papillary, thyroid lobe, isthmus, completion thyroidectomy, thyroidectomy, paratracheal, lobectomy,

Completion thyroidectomy is a surgical procedure often used to manage thyroid cancer, which can be a high-stakes situation due to risks associated with anesthesia, potential nerve damage, and complications like bleeding and infection. The patient's history of papillary thyroid carcinoma adds complexity, as the surgery involves dissecting areas close to critical structures such as the recurrent laryngeal nerve. Although not necessarily life-threatening, the stakes are elevated due to the necessity of careful surgical technique to prevent complications that could impact the patient's quality of life, such as vocal nerve damage and permanent hypocalcemia. The high level of detailed pre-surgical planning and the need for post-operative management also contribute to the stakes.


Medical Specialty: Emergency Room Reports
Sample Name: Testicular Pain

CHIEF COMPLAINT: , Testicular pain.,HISTORY OF PRESENT ILLNESS:,  The patient is a 4-year-old boy with a history of abrupt onset of left testicular pain at 11:30 this morning.  He was unable to walk and would not stand upright, and had fairly significant discomfort, so the parents checked his panel because of it.  Because of this, they took him to Emergency Department, at which time, he had no swelling noted initially, but very painful.  He had no voiding or stooling problems.  No nausea, vomiting or fever.  Family denies trauma or dysuria.  At that time, he was going to get an ultrasound done, but the mother said that all of sudden the patient stated the pain had resolved.  He has had hot chocolate this morning at 10:30 in the morning and water around 2:30 in the morning.  He has not had any pain since but states that he has had pain in the past, not as long and states there was a twisting sensation.  He has no recent cold or flu, although he had rhinorrhea about 3 weeks ago.  He is on no medications and he is here for evaluation.,PAST MEDICAL HISTORY:,  The patient has no known allergies.  He is term delivery via spontaneous vaginal delivery.  He has had no problems or hospitalizations with circumcision.,PAST SURGICAL HISTORY: , He has had no previous surgeries.,REVIEW OF SYSTEMS:,  All 14-point review of systems were negative except for the above left testicular pain and the history of possible upper respiratory infection about 2 to 3 weeks ago.,IMMUNIZATIONS: , Up-to-date.,FAMILY HISTORY: , The patient lives at home with both parents who are Spanish speaking.  He is not in school.,MEDICATIONS:,  He is on no medications.,PHYSICAL EXAMINATION:,VITAL SIGNS:  On physical exam, weight is 15.9 kg.,GENERAL:  The patient is a cooperative little boy.,HEENT:  Normal head and neck exam.  No oral or nasal discharge.,NECK:  Without masses.,CHEST:  Without masses.,LUNGS:  Clear.,CARDIAC:  Without murmurs or gallops.,ABDOMEN:  Soft.  No masses or tenderness.  His scrotum did not have any swelling at the present time.  There was only minimal discomfort with palpation at the left inguinal area, but no masses were noted.  No palpable nodules such as appendix testis and no swelling was noted and he had mild epididymal swelling only.  His left testis was slightly harder than the right, but this was not very significant.,EXTREMITIES:  He had full range of motion in all 4 extremities.,SKIN:  Warm, pink, and dry.,NEUROLOGIC:  Grossly intact.,LABORATORY DATA: , Ultrasound was obtained today showing no blood flow or poor blood flow on the left except for increased blood flow to the epididymis on the study done at about 1330 hours, and second one done around 1630 hours was normal flow, possible increased flow on the left.  This is personally reviewed by me.  The right was normal.  No masses were appreciated.  There was some mild change in echotexture on the left on the initial study, which had apparently resolved on the second, but may be due to the technical aspects of the study.,ASSESSMENT/PLAN: , The patient has a possibly torsion detorsion versus other acute testicular problem.  If the patient has indeed testicular torsion, there is an increased possibility that it may reoccur again, actually within the first 24 to 36 hours and as such is recommended doing a left scrotal exploration with possible detorsion of left testis, possible orchiectomy if the testis is markedly abnormal or nonviable, which probably is not the case, and bilateral testes fixation if the torsion is found.  I discussed the pre and postsurgical care with the parents.  Procedure itself with potential complications, risks, benefits, and alternatives of surgery including that the torsion could occur again, although it is less likely after the surgical fixation procedure.  The parents understand and wished to proceed.  We will schedule this later today emergently.
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DESCRIPTION: The patient has a possibly torsion detorsion versus other acute testicular problem.

Testicular torsion is a surgical emergency because it can lead to loss of the testicle if not treated promptly. The situation describes a young child experiencing sudden testicular pain with observed changes in blood flow on ultrasound, indicative of possible testicular torsion. This requires emergent surgical intervention to prevent complications such as loss of the testicle or permanent damage. While the immediate situation has some alleviation in pain, the risk of reoccurrence within a short timeframe makes it high-stakes due to the potential for irreversible damage.


Medical Specialty: Emergency Room Reports
Sample Name: Sickle Cell Anemia - ER Visit

HISTORY OF PRESENT ILLNESS: , This is a 19-year-old known male with sickle cell anemia.  He comes to the emergency room on his own with 3-day history of back pain.  He is on no medicines.  He does live with a room mate.  Appetite is decreased.  No diarrhea, vomiting.  Voiding well.  Bowels have been regular.  Denies any abdominal pain.  Complains of a slight headaches, but his main concern is back ache that extends from above the lower T-spine to the lumbosacral spine.  The patient is not sure of his immunizations.  The patient does have sickle cell and hemoglobin is followed in the Hematology Clinic.,ALLERGIES: , THE PATIENT IS ALLERGIC TO TYLENOL WITH CODEINE, but he states he can get morphine along with Benadryl.,MEDICATIONS: , He was previously on folic acid.  None at the present time.,PAST SURGICAL HISTORY: , He has had no surgeries in the past.,FAMILY HISTORY: , Positive for diabetes, hypertension and cancer.,SOCIAL HISTORY: , He denies any smoking or drug usage.,PHYSICAL EXAMINATION: , ,VITAL SIGNS:  On examination, the patient has a temp of 37 degrees tympanic, pulse was recorded at 37 per minute, but subsequently it was noted to be 66 per minute,  respiratory rate is 24 per minute and blood pressure is 149/66, recheck blood pressure was 132/72.,GENERAL:  He is alert, speaks in full sentences, he does not appear to be in distress.,HEENT:  Normal.,NECK:  Supple.,CHEST:  Clear.,HEART:  Regular.,ABDOMEN:  Soft.  He has pain over the mid to lower spine.,SKIN:  Color is normal.,EXTREMITIES:  He moves all extremities well.,NEUROLOGIC:  Age appropriate.,ER COURSE: , It was indicated to the patient that I will be drawing labs and giving him IV fluids.  Also that he will get morphine and Benadryl combination.  The patient was ordered a liter of NS over an hour, and was then maintained on D5 half-normal saline at 125 an hour.  CBC done showed white blood cells 4300, hemoglobin 13.1 g/dL, hematocrit 39.9%, platelets 162,000, segs 65.9, lymphs 27, monos 3.4.  Chemistries done were essentially normal except for a total bilirubin of 1.6 mg/dL, all of which was indirect.  The patient initially received morphine and diphenhydramine at 18:40 and this was repeated again at 8 p.m.  He received morphine 5 mg and Benadryl 25 mg.  I subsequently spoke to Dr. X and it was decided to admit the patient.,The patient initially stated that he wanted to be observed in the ER and given pain control and fluids and wanted to go home in the morning.  He stated that he has a job interview in the morning.  The resident service did come to evaluate him.  The resident service then spoke to Dr. X and it was decided to admit him on to the Hematology service for control of pain and IV hydration.  He is to be transitioned to p.o. medications about 4 a.m. and hopefully, he can be discharged in time to make his interview tomorrow.,IMPRESSION:  ,Sickle cell crisis.,DIFFERENTIAL DIAGNOSIS: , Veno-occlusive crisis, and diskitis.
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DESCRIPTION: A 19-year-old known male with sickle cell anemia comes to the emergency room on his own with 3-day history of back pain.

The situation involves a 19-year-old male with sickle cell anemia experiencing what could be a sickle cell crisis, characterized by severe back pain lasting for three days. Sickle cell crises can cause significant complications, including severe pain and organ damage, and require medical intervention. Although the patient wants to leave for a job interview, medical professionals have decided to admit him for pain management and IV hydration. This indicates the situation is urgent and potentially serious, given the nature of sickle cell anemia complications and the immediate medical response. Therefore, it is a high-stakes medical situation.